Clinical assessment scores: practice problems with step-by-step solutions
Also called: Glasgow Coma Scale · NEWS2 · Braden scale · Morse fall scale
Free Clinical assessment scores practice problems with diagrams, hints and full worked solutions. New values every time, at three levels: GCS, APGAR, MAP and BMI, Braden, Morse, NEWS2 and shock index, risk categories and interpretation.
Free practice problemEasy
Practice exercise (made-up values, not clinical guidance). At 5 minutes after birth, a practice newborn has blue or pale skin all over, a heart rate of 65/min, no response to stimulation, limp limbs with no muscle tone and no breathing. What is the APGAR score?
Assessment scores turn observations into a number, so that every nurse records the same patient the same way and a change over time is easy to see. Each score has fixed parts, fixed points per part and published cut-offs.
This topic practises the arithmetic and the reading of the score tables:
Neurological and newborn: Glasgow Coma Scale (GCS) and APGAR.
Derived values: mean arterial pressure, pulse pressure, shock index and body mass index.
Scores support clinical judgement; they never replace it. Charts and cut-offs vary between hospitals, so always use the version your course or workplace gives.
2Glasgow Coma Scale and APGAR
The GCS adds the best response in three areas:
Eyes (E, 1–4): spontaneous 4, to sound 3, to pressure 2, none 1.
Motor (M, 1–6): obeys commands 6, localises 5, normal flexion (withdraws) 4, abnormal flexion 3, extension 2, none 1.
The total runs from 3 to 15. After a head injury, 13–15 is usually called mild, 9–12 moderate and 3–8 severe.
The APGAR score checks a newborn at 1 and 5 minutes: Appearance, Pulse, Grimace, Activity and Respiration, each 0, 1 or 2. A pulse below 100/min scores 1; 100/min or more scores 2. A total of 7–10 is reassuring, 4–6 moderately abnormal and 0–3 low.
Self-check A patient opens the eyes to pressure, makes incomprehensible sounds and withdraws a limb from pressure. What is the GCS?
10
7
8
9
Answer: 8. E2 (to pressure) + V2 (incomprehensible sounds) + M4 (withdraws, normal flexion) = 8. Scoring the withdrawal as localising (5) gives 9.
3Braden and Morse
The Braden scale rates pressure-injury risk with six subscales. Sensory perception, moisture, activity, mobility and nutrition score 1 (worst) to 4 (no problem); friction and shear scores 1 to 3. The total runs from 6 to 23, and a lower total means a higher risk.
Common Braden bands: 19–23 not at risk, 15–18 mild, 13–14 moderate, 10–12 high and 9 or below very high risk.
The Morse fall scale adds six items: a fall in the last 3 months 25, a secondary diagnosis 15, a walking aid 15 (furniture walking 30), IV therapy or a saline lock 20, a weak gait 10 (impaired 20) and forgetting one’s limits 15. The total runs from 0 to 125.
Morse cut-offs differ between hospitals; a common set is 0–24 low, 25–44 moderate and 45 or more high.
Self-check A patient fell last month, has one diagnosis, walks with a walker, has no IV, a weak gait and knows their limits. What is the Morse score?
35
40
50
65
Answer: 50. Fall 25 + secondary diagnosis 0 + walker 15 + no IV 0 + weak gait 10 + mental status 0 = 50.
4NEWS2
The National Early Warning Score 2 (Royal College of Physicians, 2017) scores seven observations with a chart: respiration rate, SpO₂ (scale 1 for most patients), air or supplemental oxygen, systolic blood pressure, pulse, consciousness on the ACVPU scale and temperature.
Each value falls in a band worth 0, 1, 2 or 3. Supplemental oxygen scores 2, and new confusion, response only to voice or pain, or no response scores 3.
Clinical risk: a total of 0–4 is low; a score of 3 in any single parameter is low–medium; 5–6 is medium; 7 or more is high.
A total of 5 or more, or any single 3, calls for a prompt review by a clinician. SpO₂ scale 2 is used only for patients with a prescribed target of 88–92%.
Self-check A patient’s observations score 0, 0, 0, 3, 0, 0 and 0 on NEWS2. Which risk group is that?
High
Low
Low–medium
Medium
Answer: Low–medium. The total is only 3, which on its own would be low, but a score of 3 in any single parameter puts the patient in the low–medium group.
5Blood pressure values and BMI
PP = SBP − DBP MAP = (SBP + 2·DBP)/3 SI = HR/SBP
The diastolic pressure counts twice in the mean arterial pressure because about two thirds of each heartbeat is diastole. A MAP of at least about 65 mmHg is a common target. The shock index is normally about 0.5–0.7; above about 1 is a warning sign.
BMI = kg/m² BMI = 703 × lb/in²
WHO adult categories: below 18.5 underweight, 18.5–24.9 healthy, 25–29.9 overweight, 30–34.9 obesity class I, 35–39.9 class II, 40 or more class III.
Worked example
A patient’s blood pressure is 96/54 mmHg and the pulse is 118/min. Find the MAP and the shock index.
1
Mean arterial pressure
MAP = (96 + 2·54)/3 = 204/3 = 68 mmHg
2
Shock index
SI = 118/96 = 1.23
The systolic pressure, the first number, goes underneath.
Answer
MAP 68 mmHg and shock index 1.23, above 1: a warning sign in this practice case.
6Common mistakes
Starting the GCS at 0: the lowest possible score is 3.
Confusing localising (5) with withdrawing (4), or confused speech (4) with inappropriate words (3).
Scoring friction and shear up to 4 on the Braden scale; it stops at 3.
Forgetting that a single NEWS2 score of 3 raises the risk group.
Taking the simple average of SBP and DBP as the MAP.
Using the height in centimetres in the BMI formula.
7How exam questions look
Easy: GCS, APGAR, MAP and BMI. Add the GCS or APGAR from described responses and calculate MAP, pulse pressure and BMI.
Medium: Braden, Morse, NEWS2 and shock index. Add up the risk scores, use the NEWS2 chart, calculate the shock index and grade a head injury by its GCS.
Hard: risk categories and interpretation. Click the NEWS2 risk group, the Braden or Morse risk level, the APGAR meaning or the BMI category, and work back from a MAP target to a diastolic pressure.
Practice exercise (made-up values, not clinical guidance). At 5 minutes after birth, a practice newborn has pink skin all over, a heart rate of 125/min, a grimace when stimulated, active movement and slow, irregular breathing with a weak cry. What is the APGAR score?
5 minHR 125/min
Find APGAR
Show hints
Five signs: Appearance, Pulse, Grimace, Activity, Respiration; each scores 0, 1 or 2.
Pulse: none 0, below 100/min 1, 100/min or more 2.
Appearance scores 2 and Pulse scores 2.
Show the answer and the step-by-step solution
APGAR score: five signs, each scored 0, 1 or 2, checked at 1 and 5 minutes after birth. Appearance (colour): blue or pale 0, pink body with blue extremities 1, pink all over 2. Pulse: absent 0, below 100/min 1, 100/min or more 2. Grimace (reflex irritability): none 0, grimace 1, cry, cough or sneeze 2. Activity (tone): limp 0, some flexion 1, active movement 2. Respiration: absent 0, slow or irregular with a weak cry 1, good with a strong cry 2. A total of 7–10 is reassuring, 4–6 moderately abnormal and 0–3 low.
Score each sign
Appearance: pink skin all over → 2
Pulse: 125/min → 2
Grimace: a grimace when stimulated → 1
Activity: active movement → 2
Respiration: slow, irregular breathing with a weak cry → 1
Add
APGAR = 2 + 2 + 1 + 2 + 1 = 8
Answer
APGAR = 8
Example 2Medium
Practice exercise (made-up values, not clinical guidance). A practice patient after a head injury opens the eyes only to pressure (a painful stimulus), says inappropriate, random words and shows as the best motor response: extension of the arms and legs (abnormal extension). Work out the GCS and classify the head injury by it. Click your answer.
1mild
2moderate
3severe
Show hints
First add E + V + M.
The total here is 7.
13–15 mild, 9–12 moderate, 3–8 severe.
Show the answer and explanation
Glasgow Coma Scale: add the best response in three areas. Eye opening E: 4 spontaneous, 3 to sound or speech, 2 to pressure, 1 none. Verbal V: 5 oriented, 4 confused, 3 inappropriate words, 2 incomprehensible sounds, 1 none. Motor M: 6 obeys commands, 5 localises, 4 normal flexion (withdraws), 3 abnormal flexion, 2 extension, 1 none. The total runs from 3 to 15. After a head injury, 13–15 is usually called mild, 9–12 moderate and 3–8 severe.
Score each area
E: opens the eyes only to pressure (a painful stimulus) → 2
V: says inappropriate, random words → 3
M: extension of the arms and legs (abnormal extension) → 2
Add
GCS = 2 + 3 + 2 = 7
Severity
GCS 7 → severe
Answer
severe
Example 3Hard
Practice exercise (made-up values, not clinical guidance). An adult weighs 149 kg and is 197 cm tall. Calculate the BMI and click the WHO weight category.
149 kg197 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
Show hints
BMI = kg/m²: convert the height to metres and square it.
The BMI here is about 38.4 kg/m².
Bands: 18.5, 25, 30, 35 and 40.
Show the answer and explanation
Body mass index: BMI = weight (kg)/height (m)², with the height converted to metres first. With pounds and inches, BMI = 703 × weight (lb)/height (in)². WHO adult categories: below 18.5 underweight, 18.5–24.9 healthy weight, 25.0–29.9 overweight, 30.0–34.9 obesity class I, 35.0–39.9 obesity class II and 40 or more obesity class III.
BMI
BMI = 149/1.97² = 38.39
Category
obesity class II
Answer
obesity class II
Questions and answers
What is Clinical assessment scores?
Assessment scores turn observations into a number, so that every nurse records the same patient the same way and a change over time is easy to see. Each score has fixed parts, fixed points per part and published cut-offs.
This topic practises the arithmetic and the reading of the score tables:
How do I solve Clinical assessment scores problems step by step?
Find the score sheet that the question uses and its range (GCS 3–15, APGAR 0–10, Braden 6–23, Morse 0–125).
Score every item separately, matching the description to its level.
Add the item scores and check that the total lies inside the range.
Apply the cut-offs: for NEWS2 also look for any single parameter scoring 3.
For derived values use MAP = (SBP + 2·DBP)/3, PP = SBP − DBP, SI = HR/SBP and BMI = kg/m².
What are common mistakes in Clinical assessment scores?
Starting the GCS at 0 instead of 1 per area.
Confusing localising (M5) with withdrawing (M4).
Scoring Braden friction and shear up to 4.
Missing the low–medium NEWS2 group for a single score of 3.
Using the plain average of SBP and DBP as the MAP.
Forgetting to convert the height to metres for the BMI.
What do the Clinical assessment scores exercises cover?
Easy: GCS, APGAR, MAP and BMI
Medium: Braden, Morse, NEWS2 and shock index
Hard: risk categories and interpretation
Every problem has new values, so you learn the method instead of an answer. Stuck? Open a small hint first, and the full explanation only when you need it.
How practising works
Every problem has new values, so you learn the method instead of an answer.
Stuck? Open a small hint first, and the full explanation only when you need it.
Your progress, mistakes and saved problems are kept, so you can review before the exam.