Want to test your assessment knowledge before the NCLEX-RN exam? Below are free sample flashcards from the 10-card assessment section of our 1030-card NCLEX-RN (National Council Licensure Examination for Registered Nurses) deck, which covers GCS, Glasgow Coma Scale, Verbal Response and more.
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A patient with a traumatic brain injury opens eyes to pressure, makes incomprehensible sounds, and withdraws from painful stimuli. What is the Glasgow Coma Scale (GCS) score, and what is the priority nursing action?
Show answer →GCS Score: 8 (Eyes: 2, Verbal: 2, Motor: 4). Rationale: Eyes to pressure = 2; Incomprehensible sounds = 2; Withdrawal from pain = 4. NCLEX Strategy: A GCS score of 8 or less typically indicates a coma and requires immediate airway protection (Endotracheal Intubation). Less than 8, intubate is a high-yield rule. Priority: Assess airway patency and prepare for intubation. Common distractor: Choosing a score of 9 (confusing withdrawal with localizing) or 7 (missing a point in verbal).
During a neuro assessment, the nurse notes the patient's arms are adducted and internally rotated with wrists flexed on the chest. How is this documented, and what does it indicate regarding the level of brain injury?
Show answer →Documentation: Decorticate Posturing (Flexion). Rationale: This indicates damage to the cerebral hemispheres or cervical spinal cord. Clinical Pearl: Compare this to Decerebrate Posturing (Extension), where arms are stiffly extended and pronated. Decerebrate is more serious, indicating brainstem damage. NCLEX often tests the ability to distinguish these; remember De-COR-ticate moves toward the COR (core/center).
Which clinical findings constitute Cushing's Triad, and how does this presentation differ from the vital sign changes seen in distributive shock?
Show answer →Cushing's Triad (Late sign of increased ICP): 1. Bradycardia 2. Widened Pulse Pressure (Systolic HTN) 3. Irregular Respirations (e.g., Cheyne-Stokes). Contrast: In Shock (except neurogenic), you typically see Tachycardia and Hypotension. NCLEX Strategy: Cushing's Triad is a medical emergency indicating impending brain herniation. Do not confuse this with the early signs of ICP elevation, such as altered LOC or headache.
When assessing the Verbal Response of the GCS, the patient uses recognizable words but they do not make sense in the context of the conversation and are not formed into sentences. What score is assigned?
Show answer →Score: 3 (Inappropriate Words). Rationale: 5 = Oriented (knows name, place, date). 4 = Confused (speaks in sentences but disoriented). 3 = Inappropriate Words (random words, no sustained conversation). 2 = Incomprehensible Sounds (moaning, groaning). 1 = No response. NCLEX Distinction: Differentiating between 3 and 4 is common. If they can hold a conversation but think it's 1995, it's a 4. If they just say Apple... blue... help, it's a 3.
A patient has a GCS of 14 at 0800. At 0830, the GCS is 12. The pupils remain equal and reactive. What is the nurse's priority action?
Show answer →Priority: Immediate notification of the Rapid Response Team or Healthcare Provider. Rationale: A decrease in GCS of 2 or more points is a significant clinical change indicating neurological deterioration. NCLEX Strategy: Altered Level of Consciousness (LOC) is the EARLIEST and most sensitive indicator of increased ICP. Do not wait for pupillary changes or Cushing's Triad (late signs) to intervene. Assessment vs. Implementation: Assessment has already occurred (GCS drop), now the nurse must act (notify).
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1,030 NCLEX-RN question-and-answer cards across 21 topics, written for this exam. Refund policy.
The full NCLEX-RN deck contains 1030 flashcards, and 10 of them focus on assessment. This page shows 5 free samples.
Our NCLEX-RN deck dedicates 10 of 1030 cards (1%) to assessment — always cross-check the official NCSBN exam outline for the current blueprint weighting.
Yes — the samples on this page are free, and the NCLEX-RN preview page has 30 more free cards. Full access to all 1030 cards is a one-time $7.
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