CNO CNO - College of Nurses of Ontario Health Assessment and Clinical Decision Making 1

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?

Accepted Answer

Notify the physician immediately as this may indicate a neurological emergency

Answer

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?

Accepted Answer

Understanding (what the client thinks is causing the pain)

Answer

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?

Accepted Answer

Fluid accumulation such as pulmonary edema or pneumonia

Answer

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?

Accepted Answer

When a client presents with a new or changing specific symptom or concern

Answer

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?

Accepted Answer

Interpretation and pattern recognition

Answer

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.

CNO - College of Nurses of Ontario Practice Test

CNO - College of Nurses of Ontario Practice Test

CNO CNO - College of Nurses of Ontario Health Assessment and Clinical Decision Making 1