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“NURSING COMPREHENSIVE EXAM “ NEWEST UPDATED
EXAM 2025 – 2026 SOLVED QUESTIONS & ANSWERS
VERIFIED 100% GRADED A+ (LATEST VERSION)
Exam 1 Test Bank
A 63-year-old patient who began experiencing right arm and leg weakness is
admitted to the emergency department. In which order will the nurse
implement these actions included in the stroke protocol?
a. Obtain computed tomography (CT) scan without contrast.
b. Infuse tissue plasminogen activator (tPA).
c. Administer oxygen to keep O2 saturation >95%.
d. Use National Institute of Health Stroke Scale to assess patient.
C, D, A, B
The initial actions should be those that help with airway, breathing, and circulation.
Baseline neurologic assessments should be done next. A CT scan will be needed to
rule out hemorrhagic stroke before tPA can be administered.
.
.
A 68-year-old patient who is hospitalized with pneumonia is disoriented and
confused 3 days after admission. Which information indicates that the patient
is experiencing delirium rather than dementia?
a. The patient was oriented and alert when admitted.
b. The patients speech is fragmented and incoherent.
c. The patient is oriented to person but disoriented to place and time.
d. The patient has a history of increasing confusion over several years.
A
The onset of delirium occurs acutely.
The degree of disorientation does not differentiate between delirium and dementia.
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Increasing confusion for several years is consistent with dementia. Fragmented and
incoherent speech may occur with either delirium or dementia.
.
Which intervention will the nurse include in the plan of care for a patient with
moderate dementia who had an appendectomy 2 days ago?
A. Provide complete personal hygiene care for the patient.
B. Remind the patient frequently about being in the hospital.
C. Reposition the patient frequently to avoid skin breakdown.
D. Place suction at the bedside to decrease the risk for aspiration
B
The patient with moderate dementia will have problems with short- and long-term
memory and will need reminding about the hospitalization.
The other interventions would be used for a patient with severe dementia, who would
have difficulty with swallowing, self-care, and immobility.
.
When administering a mental status examination to a patient with delirium, the
nurse should
A. wait until the patient is well-rested.
b. administer an anxiolytic medication.
c. choose a place without distracting stimuli.
d. reorient the patient during the examination.
.
C
Because overstimulation by environmental factors can distract the patient from the
task of answering the nurses questions, these stimuli should be avoided.
The nurse will not wait to give the examination because action to correct the delirium
should occur as soon as possible. Reorienting the patient is not appropriate during
the examination. Antianxiety medications may increase the patients delirium.
.
The nurse is concerned about a postoperative patients risk for injury during an
episode of delirium. The most appropriate action by the nurse is to
a. secure the patient in bed using a soft chest restraint.
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b. ask the health care provider to order an antipsychotic drug.
c. instruct family members to remain with the patient and prevent injury.
d. assign unlicensed assistive personnel (UAP) to stay with the patient and
offer reorientation.
D
The priority goal is to protect the patient from harm. Having a UAP stay with the
patient will ensure the patients safety.
Visits by family members are helpful in reorienting the patient, but families should not
be responsible for protecting patients from injury. Antipsychotic medications may be
ordered, but only if other measures are not effective because these medications
have many side effects. Restraints are not recommended because they can increase
the patients agitation and disorientation.
A 56-year-old patient in the outpatient clinic is diagnosed with mild cognitive
impairment (MCI). Which action will the nurse include in the plan of care?
a. Suggest a move into an assisted living facility.
b. Schedule the patient for more frequent appointments.
c. Ask family members to supervise the patients daily activities.
d. Discuss the preventive use of acetylcholinesterase medications.
B
Ongoing monitoring is recommended for patients with MCI.
MCI does not interfere with activities of daily living, acetylcholinesterase drugs are
not used for MCI, and an assisted living facility is not indicated for MCI.
.
The nurse is administering a mental status examination to a 48-year-old
patient who has hypertension. The nurse suspects depression when the
patient responds to the nurses questions with
a. Is that right?
b. I dont know.
c. Wait, let me think about that.
d. Who are those people over there?
B
Answers such as I dont know are more typical of depression than dementia. The
response
Who are those people over there? is more typical of the distraction seen in a patient
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with delirium. The remaining two answers are more typical of a patient with mild to
moderate dementia.
.
A 68-year-old patient is diagnosed with moderate dementia after multiple
strokes. During assessment of the patient, the nurse would expect to find
a. excessive nighttime sleepiness.
b. difficulty eating and swallowing.
c. loss of recent and long-term memory.
d. fluctuating ability to perform simple tasks.
C
Loss of both recent and long-term memory is characteristic of moderate dementia.
Patients with dementia have frequent nighttime awakening. Dementia is progressive,
and the patients ability to perform tasks would not have periods of improvement.
Difficulty eating and swallowing is characteristic of severe dementia.
.
Which action will help the nurse determine whether a new patients confusion
is caused by dementia or delirium?
a. Administer the Mini-Mental Status Exam.
b. Use the Confusion Assessment Method tool.
c. Determine whether there is a family history of dementia.
d. Obtain a list of the medications that the patient usually takes.
.
B
The Confusion Assessment Method tool has been extensively tested in assessing
delirium.
The other actions will be helpful in determining cognitive function or risk factors for
dementia or delirium, but they will not be useful in differentiating between dementia
and delirium.
.
A 72-year-old female patient is brought to the clinic by the patients spouse,
who reports that she is unable to solve common problems around the house.
To obtain information about the patients current mental status, which question
should the nurse ask the patient?
“NURSING COMPREHENSIVE EXAM “ NEWEST UPDATED
EXAM 2025 – 2026 SOLVED QUESTIONS & ANSWERS
VERIFIED 100% GRADED A+ (LATEST VERSION)
Exam 1 Test Bank
A 63-year-old patient who began experiencing right arm and leg weakness is
admitted to the emergency department. In which order will the nurse
implement these actions included in the stroke protocol?
a. Obtain computed tomography (CT) scan without contrast.
b. Infuse tissue plasminogen activator (tPA).
c. Administer oxygen to keep O2 saturation >95%.
d. Use National Institute of Health Stroke Scale to assess patient.
C, D, A, B
The initial actions should be those that help with airway, breathing, and circulation.
Baseline neurologic assessments should be done next. A CT scan will be needed to
rule out hemorrhagic stroke before tPA can be administered.
.
.
A 68-year-old patient who is hospitalized with pneumonia is disoriented and
confused 3 days after admission. Which information indicates that the patient
is experiencing delirium rather than dementia?
a. The patient was oriented and alert when admitted.
b. The patients speech is fragmented and incoherent.
c. The patient is oriented to person but disoriented to place and time.
d. The patient has a history of increasing confusion over several years.
A
The onset of delirium occurs acutely.
The degree of disorientation does not differentiate between delirium and dementia.
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Increasing confusion for several years is consistent with dementia. Fragmented and
incoherent speech may occur with either delirium or dementia.
.
Which intervention will the nurse include in the plan of care for a patient with
moderate dementia who had an appendectomy 2 days ago?
A. Provide complete personal hygiene care for the patient.
B. Remind the patient frequently about being in the hospital.
C. Reposition the patient frequently to avoid skin breakdown.
D. Place suction at the bedside to decrease the risk for aspiration
B
The patient with moderate dementia will have problems with short- and long-term
memory and will need reminding about the hospitalization.
The other interventions would be used for a patient with severe dementia, who would
have difficulty with swallowing, self-care, and immobility.
.
When administering a mental status examination to a patient with delirium, the
nurse should
A. wait until the patient is well-rested.
b. administer an anxiolytic medication.
c. choose a place without distracting stimuli.
d. reorient the patient during the examination.
.
C
Because overstimulation by environmental factors can distract the patient from the
task of answering the nurses questions, these stimuli should be avoided.
The nurse will not wait to give the examination because action to correct the delirium
should occur as soon as possible. Reorienting the patient is not appropriate during
the examination. Antianxiety medications may increase the patients delirium.
.
The nurse is concerned about a postoperative patients risk for injury during an
episode of delirium. The most appropriate action by the nurse is to
a. secure the patient in bed using a soft chest restraint.
, Page 3 of 212
b. ask the health care provider to order an antipsychotic drug.
c. instruct family members to remain with the patient and prevent injury.
d. assign unlicensed assistive personnel (UAP) to stay with the patient and
offer reorientation.
D
The priority goal is to protect the patient from harm. Having a UAP stay with the
patient will ensure the patients safety.
Visits by family members are helpful in reorienting the patient, but families should not
be responsible for protecting patients from injury. Antipsychotic medications may be
ordered, but only if other measures are not effective because these medications
have many side effects. Restraints are not recommended because they can increase
the patients agitation and disorientation.
A 56-year-old patient in the outpatient clinic is diagnosed with mild cognitive
impairment (MCI). Which action will the nurse include in the plan of care?
a. Suggest a move into an assisted living facility.
b. Schedule the patient for more frequent appointments.
c. Ask family members to supervise the patients daily activities.
d. Discuss the preventive use of acetylcholinesterase medications.
B
Ongoing monitoring is recommended for patients with MCI.
MCI does not interfere with activities of daily living, acetylcholinesterase drugs are
not used for MCI, and an assisted living facility is not indicated for MCI.
.
The nurse is administering a mental status examination to a 48-year-old
patient who has hypertension. The nurse suspects depression when the
patient responds to the nurses questions with
a. Is that right?
b. I dont know.
c. Wait, let me think about that.
d. Who are those people over there?
B
Answers such as I dont know are more typical of depression than dementia. The
response
Who are those people over there? is more typical of the distraction seen in a patient
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with delirium. The remaining two answers are more typical of a patient with mild to
moderate dementia.
.
A 68-year-old patient is diagnosed with moderate dementia after multiple
strokes. During assessment of the patient, the nurse would expect to find
a. excessive nighttime sleepiness.
b. difficulty eating and swallowing.
c. loss of recent and long-term memory.
d. fluctuating ability to perform simple tasks.
C
Loss of both recent and long-term memory is characteristic of moderate dementia.
Patients with dementia have frequent nighttime awakening. Dementia is progressive,
and the patients ability to perform tasks would not have periods of improvement.
Difficulty eating and swallowing is characteristic of severe dementia.
.
Which action will help the nurse determine whether a new patients confusion
is caused by dementia or delirium?
a. Administer the Mini-Mental Status Exam.
b. Use the Confusion Assessment Method tool.
c. Determine whether there is a family history of dementia.
d. Obtain a list of the medications that the patient usually takes.
.
B
The Confusion Assessment Method tool has been extensively tested in assessing
delirium.
The other actions will be helpful in determining cognitive function or risk factors for
dementia or delirium, but they will not be useful in differentiating between dementia
and delirium.
.
A 72-year-old female patient is brought to the clinic by the patients spouse,
who reports that she is unable to solve common problems around the house.
To obtain information about the patients current mental status, which question
should the nurse ask the patient?
