CNO CNO - College of Nurses of Ontario Health Assessment and Clinical Decision Making 2

Question 1

A nurse is performing a Glasgow Coma Scale (GCS) assessment. Which three components are evaluated?

Accepted Answer

Eye opening, verbal response, and motor response

Answer

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?

Accepted Answer

SpO2 of 88% on room air with altered mental status

Answer

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?

Accepted Answer

MMSE (Mini-Mental State Examination)

Answer

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?

Accepted Answer

Abnormal — may indicate poor peripheral perfusion

Answer

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?

Accepted Answer

Using validated research evidence combined with clinical expertise and client preferences

Answer

Evidence-based practice requires integrating best available research, clinical expertise, and client preferences to guide nursing decisions.

CNO - College of Nurses of Ontario Practice Test