American Association of Critical-Care Nurses (AACN) Certification Practice Test

In the context of qSOFA, how is altered mental status indicated?

1. GCS less than 12

2. Any GCS less than 15

3. GCS less than 10

4. GCS less than 8

The correct answer is: Any GCS less than 15

Altered mental status in the context of the quick Sequential Organ Failure Assessment (qSOFA) is indicated by a Glasgow Coma Scale (GCS) score of less than 15. The qSOFA tool helps to identify patients at risk of sepsis based on three clinical criteria: respiratory rate, altered mental status, and systolic blood pressure. An important aspect of this assessment is recognizing changes in a patient's level of consciousness. Since the maximum GCS score is 15, a score below this indicates some degree of altered mental status. The cut-off of less than 15 is significant because it captures any departure from baseline mental function, while higher thresholds are too restrictive to identify patients potentially at risk of severe outcomes. Thus, identifying any GCS less than 15 effectively flags altered mental status in relation to sepsis risk.