Want to test your assessment knowledge before the CCRN exam? Below are free sample flashcards from the 40-card assessment section of our 1000-card CCRN (Critical Care Registered Nurse) deck, which covers GCS, Glasgow Coma Scale and more.
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A 45-year-old intubated patient follows commands and opens eyes to speech but cannot provide a verbal response. How should the nurse accurately document the Glasgow Coma Scale (GCS) score?
Show answer →The GCS should be documented as 10T (E4, V1t, M5). When a patient is intubated, the verbal component is scored as a 1 and the suffix T or t is added. Exam Strategy: The AACN emphasizes that you must NOT assign a verbal score higher than 1 for an intubated patient, even if they appear to be mouthing words. Always use the best response for each category. A change in GCS of ≥2 points is clinically significant and requires immediate notification to the provider.
A patient with a left-sided intracranial hemorrhage localizes to pain with the right arm but shows only extension (decerebrate) with the left arm. What is the correct GCS Motor score?
Show answer →GCS Motor Score: 5. Rationale: When GCS scores are asymmetrical, the Best response is used to calculate the total GCS score for the purpose of standardized communication and prognosis. Clinical Practice: While the total score uses the best response, the nurse must document the asymmetry in the medical record, as the difference between limbs is a critical diagnostic finding for localized brain injury.
A patient has periorbital ecchymosis (raccoon eyes) and clear fluid draining from the nose. Which Secondary Survey intervention is strictly contraindicated?
Show answer →**Nasogastric (NG) Tube insertion**. These findings (including Battle's sign/hemotympanum) indicate a **Basilar Skull Fracture**. NG tubes can inadvertently enter the cranial vault through the cribriform plate. Use an Orogastric (OG) tube instead. Also, avoid Nasopharyngeal airways (NPA) in these patients. Key Exam Point: Recognize these physical exam findings as absolute stops for nasal instrumentation in the trauma setting.
A patient has an ulcer on the inner cheek caused by an improperly secured endotracheal tube. How is this injury staged?
Show answer →Mucosal Pressure Injury. These are found on mucous membranes with a history of a medical device in use at the location. Due to the anatomy of the tissue, these injuries cannot be staged using the 1-4 staging system. CCRN Tip: AACN and NPIAP strictly differentiate mucosal injuries from cutaneous ones. Never apply Stage 1-4 to the tongue, nares, or oral mucosa.
During the CAM-ICU assessment, how is Feature 2 (Inattention) specifically tested in a non-verbal, intubated patient?
Show answer →Feature 2 is tested using the SAVEAHAART or CASABLANCA letter strings. The nurse recites 10 letters and asks the patient to squeeze their hand only on the letter 'A'. Inattention is present if the patient makes >2 errors (squeezing on the wrong letter or failing to squeeze on 'A'). This is a mandatory component for a positive delirium diagnosis.
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Try 30 free CCRN cards firstThe full CCRN deck contains 1000 flashcards, and 40 of them focus on assessment. This page shows 5 free samples.
Our CCRN deck dedicates 40 of 1000 cards (4%) to assessment — always cross-check the official AACN exam outline for the current blueprint weighting.
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Diagnostics
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Ethics
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Management
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