Nursing Assessment, Diagnosis, and Care Planning Exam: Alzheimer’s Disease,
Dementia, Delirium, Mild Cognitive Impairment, Vascular and Frontotemporal
Dementia, Cognitive Screening, Mental Status Examination, Mini-Mental State
Exam, Confusion Assessment Method, Nursing Interventions, Pharmacologic
Management, Non-Pharmacologic Interventions, Caregiver Support,
Sundowning, Safety Measures, Daily Living Activities, Behavioral Management,
Psychosocial Support, Multidisciplinary Collaboration, Dependent and
Independent Nursing Interventions, Standardized and Individualized Care Plans,
Critical Pathways, Risk Assessment, Early Detection, Memory Impairment,
Orientation, Attention, Judgment, Decision-Making, ADL Assistance, and
Patient-Centered Nursing Strategies Exam Questions Verified and Provided with
Complete A+ Graded Rationales Latest Updated 2026
1. A patient who is hospitalized with pneumonia is disoriented and confused 2 days after admission.
Which information obtained by the nurse about the patient indicates that the patient is experiencing
delirium rather than dementia?
a. The patient was oriented and alert when admitted.
b. The patient's speech is fragmented and incoherent.
c. The patient is disoriented to place and time but oriented to person.
d. The patient has a history of increasing confusion over several years.
a. The patient was oriented and alert when admitted.
The onset of delirium occurs acutely. The degree of disorientation does not differentiate between
delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented
and incoherent speech may occur with either delirium or dementia.
2. When developing a plan of care for a hospitalized patient with moderate dementia, which
intervention will the nurse include?
,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. Remind the patient frequently about being in the hospital.
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.
3. When administering a mental status examination to a patient with delirium, the nurse should
a. medicate the patient first to reduce any anxiety.
b. give the examination when the patient is well-rested.
c. reorient the patient as needed during the examination.
d. choose a place without distracting environmental stimuli.
d. choose a place without distracting environmental stimuli.
Because overstimulation by environmental factors can distract the patient from the task of answering
the nurse's 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 patient's delirium.
4. To protect a patient from 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.
b. ask the health care provider about ordering an antipsychotic drug.
,c. instruct family members to remain with the patient and prevent injury.
d. assign a nursing assistant to stay with the patient and offer frequent reorientation.
d. assign a nursing assistant to stay with the patient and offer frequent reorientation.
The priority goal is to protect the patient from harm, and a staff member will be most experienced in
providing safe care. 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 multiple side effects. Restraints
are sometimes used but tend to increase agitation and disorientation.
5. Which action will the nurse in the outpatient clinic include in the plan of care for a patient with mild
cognitive impairment (MCI)?
a. Suggest a move into an assisted living facility.
b. Schedule the patient for more frequent appointments.
c. Ask family members to supervise the patient's daily activities.
d. Discuss the preventive use of acetylcholinesterase medications.
b. Schedule the patient for more frequent appointments.
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.
6. When administering a mental status examination to a patient, the nurse suspects depression when
the patient responds with
a. "I don't know."
b. "Is that the right answer?"
c. "Wait, let me think about that."
, d. "Who are those people over there?
a. "I don't know."
Answers such as "I don't know" are more typical of depression. The response "Who are those people
over there?" is more typical of the distraction seen in a patient with delirium. The remaining two
answers are more typical of a patient with dementia.
7. A 72-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During
assessment of the patient, the nurse would expect to find
a. excessive nighttime sleepiness.
b. difficulty eating and swallowing.
c. variable ability to perform simple tasks.
d. loss of both recent and long-term memory.
d. loss of both recent and long-term memory.
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 patient's ability to
perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic
of severe dementia.
8. To determine whether a new patient's confusion is caused by dementia or delirium, which action
should the nurse take?
a. Assess the patient using the Mini-Mental Status Exam.
b. Obtain a list of the medications that the patient usually takes.
c. Determine whether there is positive family history of dementia.
d. Use the Confusion Assessment Method tool to assess the patient.
d. Use the Confusion Assessment Method tool to assess the patient.
Dementia, Delirium, Mild Cognitive Impairment, Vascular and Frontotemporal
Dementia, Cognitive Screening, Mental Status Examination, Mini-Mental State
Exam, Confusion Assessment Method, Nursing Interventions, Pharmacologic
Management, Non-Pharmacologic Interventions, Caregiver Support,
Sundowning, Safety Measures, Daily Living Activities, Behavioral Management,
Psychosocial Support, Multidisciplinary Collaboration, Dependent and
Independent Nursing Interventions, Standardized and Individualized Care Plans,
Critical Pathways, Risk Assessment, Early Detection, Memory Impairment,
Orientation, Attention, Judgment, Decision-Making, ADL Assistance, and
Patient-Centered Nursing Strategies Exam Questions Verified and Provided with
Complete A+ Graded Rationales Latest Updated 2026
1. A patient who is hospitalized with pneumonia is disoriented and confused 2 days after admission.
Which information obtained by the nurse about the patient indicates that the patient is experiencing
delirium rather than dementia?
a. The patient was oriented and alert when admitted.
b. The patient's speech is fragmented and incoherent.
c. The patient is disoriented to place and time but oriented to person.
d. The patient has a history of increasing confusion over several years.
a. The patient was oriented and alert when admitted.
The onset of delirium occurs acutely. The degree of disorientation does not differentiate between
delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented
and incoherent speech may occur with either delirium or dementia.
2. When developing a plan of care for a hospitalized patient with moderate dementia, which
intervention will the nurse include?
,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. Remind the patient frequently about being in the hospital.
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.
3. When administering a mental status examination to a patient with delirium, the nurse should
a. medicate the patient first to reduce any anxiety.
b. give the examination when the patient is well-rested.
c. reorient the patient as needed during the examination.
d. choose a place without distracting environmental stimuli.
d. choose a place without distracting environmental stimuli.
Because overstimulation by environmental factors can distract the patient from the task of answering
the nurse's 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 patient's delirium.
4. To protect a patient from 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.
b. ask the health care provider about ordering an antipsychotic drug.
,c. instruct family members to remain with the patient and prevent injury.
d. assign a nursing assistant to stay with the patient and offer frequent reorientation.
d. assign a nursing assistant to stay with the patient and offer frequent reorientation.
The priority goal is to protect the patient from harm, and a staff member will be most experienced in
providing safe care. 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 multiple side effects. Restraints
are sometimes used but tend to increase agitation and disorientation.
5. Which action will the nurse in the outpatient clinic include in the plan of care for a patient with mild
cognitive impairment (MCI)?
a. Suggest a move into an assisted living facility.
b. Schedule the patient for more frequent appointments.
c. Ask family members to supervise the patient's daily activities.
d. Discuss the preventive use of acetylcholinesterase medications.
b. Schedule the patient for more frequent appointments.
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.
6. When administering a mental status examination to a patient, the nurse suspects depression when
the patient responds with
a. "I don't know."
b. "Is that the right answer?"
c. "Wait, let me think about that."
, d. "Who are those people over there?
a. "I don't know."
Answers such as "I don't know" are more typical of depression. The response "Who are those people
over there?" is more typical of the distraction seen in a patient with delirium. The remaining two
answers are more typical of a patient with dementia.
7. A 72-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During
assessment of the patient, the nurse would expect to find
a. excessive nighttime sleepiness.
b. difficulty eating and swallowing.
c. variable ability to perform simple tasks.
d. loss of both recent and long-term memory.
d. loss of both recent and long-term memory.
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 patient's ability to
perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic
of severe dementia.
8. To determine whether a new patient's confusion is caused by dementia or delirium, which action
should the nurse take?
a. Assess the patient using the Mini-Mental Status Exam.
b. Obtain a list of the medications that the patient usually takes.
c. Determine whether there is positive family history of dementia.
d. Use the Confusion Assessment Method tool to assess the patient.
d. Use the Confusion Assessment Method tool to assess the patient.
