# Situation: A 24-year-old man is transferred to the neurosurgical ward 2 days after a motorcycle crash. Computed tomography (CT) showed a small frontal contusion and a basilar skull fracture, with no hematoma needing surgery. His cervical spine has been cleared. He is drowsy but easily roused and slightly confused. The nurse compares two Glasgow Coma Scale (GCS) checks: 08:00 — opens eyes to voice; confused speech; obeys commands 12:00 — opens eyes spontaneously; confused speech; localizes to pressure but does not obey commands Which conclusion is correct?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630420  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 24-year-old man is transferred to the neurosurgical ward 2 days after a motorcycle crash. Computed tomography (CT) showed a small frontal contusion and a basilar skull fracture, with no hematoma needing surgery. His cervical spine has been cleared. He is drowsy but easily roused and slightly confused.

The nurse compares two Glasgow Coma Scale (GCS) checks:
08:00 — opens eyes to voice; confused speech; obeys commands
12:00 — opens eyes spontaneously; confused speech; localizes to pressure but does not obey commands
Which conclusion is correct?

## 보기

1. The total score is unchanged, so hourly checks continue
2. The motor score fell; notify the physician now **✔ 정답**
3. Eye opening improved, so he is recovering as expected
4. The score fell 1 point, which is below the level to report

**정답: 2**

## 해설

At 08:00 the score is E3 V4 M6 = 13, and at 12:00 it is E4 V4 M5 = 13. The total is unchanged only because a better eye score hides a worse motor score. Any fall in the motor score, even 1 point, is a significant sign of decline and is reported promptly, which is why each component is recorded, not just the total.

## 심화 해설

Calculating and comparing the scores
At 08:00 he opens his eyes to voice (E3), has confused speech (V4), and obeys commands (M6), for a Glasgow Coma Scale (GCS) of 13. At 12:00 he opens his eyes spontaneously (E4), still has confused speech (V4), and localizes to pressure but does not obey commands (M5), again a total of 13. The total is unchanged only because a better eye score hides a worse motor score. The motor score fell, and the nurse notifies the physician now.

Why the motor score matters most
The motor component of the GCS is the most reliable predictor of neurologic outcome and the most sensitive indicator of deterioration in a client with brain injury. Eye opening can fluctuate with stimulation and alertness, while a decline from obeying commands to merely localizing suggests worsening brain function, possibly from increasing cerebral edema, a developing hematoma, or rising intracranial pressure. Any fall in the motor score, even 1 point, is a significant sign of decline and is reported promptly, which is why each component is recorded, not just the total.

| Component | 08:00 | 12:00 | Change |
| --- | --- | --- | --- |
| Eye (E) | Opens to voice: 3 | Spontaneous: 4 | Better |
| Verbal (V) | Confused: 4 | Confused: 4 | Same |
| Motor (M) | Obeys: 6 | Localizes: 5 | Worse |
| Total | 13 | 13 | Unchanged |

Why the other conclusions are wrong
Continuing hourly checks because the total is unchanged ignores the hidden motor decline. Concluding that eye opening improved, so he is recovering gives weight to the less reliable component and misses the important change. Saying the score fell 1 point and is below the level to report is factually wrong: the total did not fall at all, and any motor decline is reportable regardless of the total.

Nursing actions
The nurse notifies the physician immediately, performs a full neurologic assessment including pupils and limb strength, checks vital signs for signs of rising intracranial pressure, and anticipates urgent repeat CT. Neurologic observations are increased in frequency.

Exam takeaway
Watch out Always break the GCS into components. An unchanged total can hide a motor decline, and a fall in the motor score is reported even when the total stays the same.

## 임상 시나리오

Reading the GCS by ComponentWhen the total hides a decline
At 08:00 the score is E3 V4 M6 = 13; at 12:00 it is E4 V4 M5 = 13. Better eye opening offsets a worse motor response, so the total is unchanged.

The motor score is the most sensitive indicator of deterioration after head injury. A fall from obeying commands to localizing is reported at once.

CautionRecord and compare each GCS component, not just the total. Check pupils and vital signs and anticipate urgent repeat CT.

## 핵심 개념

- **Glasgow Coma Scale** — A scale scoring eye opening, verbal response, and motor response to assess level of consciousness.
- **Localizing to pressure** — Moving a hand toward the site of a painful stimulus, scored M5 on the GCS.
- **Obeys commands** — Following simple instructions, the best motor response, scored M6.
- **Cerebral contusion** — A bruise of brain tissue that can swell and cause neurologic deterioration.

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