CNO CNO - College of Nurses of Ontario Health Assessment and Clinical Decision Making 1 — Questions and Answers
Question 1: During a head-to-toe assessment, a CNO-registered nurse notes that a client has unequal pupils. What is the nurse's priority action?
- Document the finding and continue the assessment
- Notify the physician immediately as this may indicate a neurological emergency (Correct answer)
- Administer prescribed pain medication
- Reposition the client and reassess in one hour
Correct answer: Notify the physician immediately as this may indicate a neurological emergency
Unequal pupils (anisocoria) can indicate a serious neurological condition such as increased intracranial pressure, requiring immediate physician notification.
Question 2: A nurse is assessing a client's pain using the PQRSTU framework. What does the 'U' stand for?
- Urgency
- Understanding (what the client thinks is causing the pain) (Correct answer)
- Unit of measurement
- Usual pattern
Correct answer: Understanding (what the client thinks is causing the pain)
In the PQRSTU mnemonic, 'U' stands for Understanding — what the client believes is causing or contributing to their pain.
Question 3: When assessing a client's lung sounds, the nurse hears crackles in the lower lobes bilaterally. This finding is most consistent with which condition?
- Asthma
- Pulmonary embolism
- Fluid accumulation such as pulmonary edema or pneumonia (Correct answer)
- Pleural effusion without fluid
Correct answer: Fluid accumulation such as pulmonary edema or pneumonia
Bilateral basal crackles are commonly associated with fluid in the alveoli, as seen in pulmonary edema or pneumonia.
Question 4: According to CNO standards, when should a nurse perform a focused assessment rather than a comprehensive assessment?
- On every client encounter regardless of status
- When a client presents with a new or changing specific symptom or concern (Correct answer)
- Only during initial admission
- Only when ordered by a physician
Correct answer: When a client presents with a new or changing specific symptom or concern
A focused assessment is appropriate when evaluating a specific symptom or change in client condition, rather than performing a full head-to-toe review.
Question 5: A nurse uses clinical reasoning to determine that a post-operative client's increased heart rate and drop in blood pressure indicate possible internal bleeding. This is an example of which step in clinical decision making?
- Data collection
- Implementation
- Interpretation and pattern recognition (Correct answer)
- Evaluation of outcomes
Correct answer: Interpretation and pattern recognition
Recognizing that a cluster of vital sign changes points to a specific clinical problem is the interpretation and pattern recognition step of clinical decision making.
Question 6: When assessing a client's skin turgor, the nurse pinches the skin on the back of the hand and notes it returns slowly. This finding suggests:
- Fluid overload
- Dehydration or decreased skin elasticity (Correct answer)
- Normal hydration status
- Allergic reaction
Correct answer: Dehydration or decreased skin elasticity
Slow skin turgor return indicates decreased tissue fluid, which can be caused by dehydration or, in older adults, by reduced skin elasticity.
CNO CNO - College of Nurses of Ontario Health Assessment and Clinical Decision Making 1
During a head-to-toe assessment, a CNO-registered nurse notes that a client has unequal pupils.
What is the nurse's priority action?