CNO CNO - College of Nurses of Ontario Health Assessment and Clinical Decision Making 2 — Questions and Answers
Question 1: A nurse is performing a Glasgow Coma Scale (GCS) assessment. Which three components are evaluated?
- Pupil reaction, motor strength, and reflexes
- Eye opening, verbal response, and motor response (Correct answer)
- Orientation, memory, and judgment
- Heart rate, blood pressure, and respiratory rate
Correct answer: Eye opening, verbal response, and motor response
The GCS assesses eye opening, verbal response, and motor response, with a maximum score of 15 indicating full consciousness.
Question 2: A nurse assesses a client and identifies a nursing diagnosis of 'impaired gas exchange.' Which finding most directly supports this diagnosis?
- Client reports feeling anxious
- SpO2 of 88% on room air with altered mental status (Correct answer)
- Blood pressure of 145/90 mmHg
- Client is unable to ambulate independently
Correct answer: SpO2 of 88% on room air with altered mental status
An SpO2 of 88% with associated altered mental status provides objective evidence of impaired gas exchange.
Question 3: During a mental status examination, which assessment tool is commonly used to screen for cognitive impairment in older adults?
- AUDIT-C
- MMSE (Mini-Mental State Examination) (Correct answer)
- PHQ-9
- GAD-7
Correct answer: MMSE (Mini-Mental State Examination)
The Mini-Mental State Examination (MMSE) is a widely used standardized tool to screen for cognitive impairment and dementia in older adults.
Question 4: A nurse notes that a client's capillary refill time is 4 seconds. How should the nurse interpret this finding?
- Normal — within acceptable range
- Abnormal — may indicate poor peripheral perfusion (Correct answer)
- Normal for elderly clients only
- Indicates fluid overload
Correct answer: Abnormal — may indicate poor peripheral perfusion
Normal capillary refill time is less than 2 seconds; a 4-second refill suggests impaired peripheral circulation.
Question 5: In clinical decision making, which action best reflects evidence-based practice as required by CNO standards?
- Relying solely on personal experience when making care decisions
- Using validated research evidence combined with clinical expertise and client preferences (Correct answer)
- Following only physician orders without independent nursing judgment
- Applying the same intervention to all clients with similar diagnoses
Correct answer: Using validated research evidence combined with clinical expertise and client preferences
Evidence-based practice requires integrating best available research, clinical expertise, and client preferences to guide nursing decisions.
Question 6: A nurse auscultates a client's abdomen before and after administering a nasogastric tube feeding. What is the purpose of this assessment?
- To measure the client's pain level
- To confirm tube placement and assess bowel sounds indicating gut motility (Correct answer)
- To detect cardiac arrhythmias
- To evaluate respiratory function
Correct answer: To confirm tube placement and assess bowel sounds indicating gut motility
Abdominal auscultation before tube feeding helps confirm bowel sounds are present and assesses gut motility, supporting safe enteral nutrition delivery.
CNO CNO - College of Nurses of Ontario Health Assessment and Clinical Decision Making 2
A nurse is performing a Glasgow Coma Scale (GCS) assessment.
Which three components are evaluated?