Classification Systems/Scales

Question 1

What score on the GCS marks someone who is in a coma?

Answer 1

8 or less

Question 2

The Glasgow Coma Scale judges someone’s severity of brain injury by 3 responses. What are they?

Answer 2

Eye opening response
Verbal response
Motor response

Question 3

What score on the GCS marks someone who is completely unresponsive?

Answer 3

3 (lowest score possible)

Question 4

T/F: Glasgow Coma Scale is hierarchical scale

Answer 4

True: GCS scores range from 3 (completely unresponsive) to 15 (best response)

Question 5

What does AAOx1 mean?

Answer 5

Patient is oriented to self: knows themselves and significant others

Question 6

What does AAOx2 mean?

Answer 6

Patient is oriented to self and place: knows themselves, significant others, and where they are

Question 7

What does AAOx3 mean?

Answer 7

Patient is oriented to self, place, and time: knows themselves, significant others, where they are, and date/day of the week/season

Question 8

What does AAOx4 mean?

Answer 8

Patient is oriented self, place, time, and situation: all components of AAOx3 but pt also comprehends and can explain why they are at the healthcare facility

Question 9

What does being “awake” mean when thinking of GCS?

Answer 9

This includes whether or not you have the ability to wake up because of voice or touch. That’s what makes a coma different from just being asleep.

Question 10

What does being “alert” mean when thinking of GCS?

Answer 10

This is how responsive you are to people talking to you and if you’re able to understand what’s happening in your immediate surroundings.

Question 11

What does being “oriented” mean when thinking of GCS?

Answer 11

This means you know who you are, where you’re at, what day it is and other details related to the here and now.

Question 12

What does the Modified Ashworth Scale (MAS) measure?

Answer 12

Measures the increase in muscle tone. MAS assigns a grade of spasticity from a 0-4 ordinal scale. The grade is assigned by moving a joint/muscle through a high velocity quick stretch.

Question 13

T/F: the MAS is a hierarchical scale.

Answer 13

True: the higher the score on the MAS, the higher a person’s tone/spasticity is.

Question 14

Modified Ashworth Scale Scoring

Answer 14

0: No increase in tone
1: slight increase in tone giving a catch when slight increase in muscle tone, manifested by the limb was moved in flexion or extension.
1+: slight increase in muscle tone, manifested by a catch followed by minimal resistance throughout (ROM )
2: more marked increase in tone but more marked increased in muscle tone through most limb easily flexed
3: considerable increase in tone, passive movement difficult
4: limb rigid in flexion or extension

Question 15

Is increased tone a sign of an upper motor or lower motor neuron lesion?

Answer 15

Upper Motor Neuron

Question 16

What is the Babinski Sign?
What does it show (UMN or LMN dysfunction)?

Answer 16

It is the dorsiflexion of the great toe with or without fanning of the other toes in response to planter stimulation.
This shows pyramidal tract dysfunction (UMN).