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NR 341 Complex Adult Health
Exam 1 | Questions with
Rationalized Answers | 100%
Guaranteed Pass | Advanced
Medical-Surgical & NCLEX-RN®
Exam Structure:
Subject: Complex Adult Health (NR 341)
Source: NR 341 Complex Adult Health Exam 1
Format: Questions and Verified Answers with Rationales
1. A nurse is caring for a group of older adult clients. Which of the
following manifestations indicates one of the clients is experiencing
delirium?
A. A client wants to know the current time while there is a clock on the wall.
B. A client attempts to climb out of bed and repeatedly states she must get
home.
C. A client requests extra blankets when the thermostat in the room
indicates 25.6°C (78°F).
D. A client refuses to get out of bed and has no motivation to attend to daily
hygiene.
Answer: B. A client attempts to climb out of bed and repeatedly states she
must get home.
Rationale:
1. Delirium is characterized by a change in cognition that occurs over a
short period of time.
2. It results from a secondary physiological condition (e.g., infection,
surgery, prolonged hospitalization, hypoxia, fever, medications).
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3. Delirium frequently progresses in the evening hours and is
sometimes called "sundown syndrome."
4. Manifestations include alterations in memory, agitation, restlessness,
illusions, or hallucinations.
2. A community health nurse is providing teaching to the family of a
client who has primary dementia. Which of the following
manifestations should the nurse tell the family to expect?
A. Decreased auditory and visual acuity.
B. Decreased display of emotion.
C. Personality traits that are opposite of original traits.
D. Forgetfulness gradually progressing to disorientation.
Answer: D. Forgetfulness gradually progressing to disorientation.
Rationale:
1. Dementia usually appears first as forgetfulness.
2. Loss of functioning progresses slowly from impaired language skills
and difficulty with ordinary daily activities to severe memory loss.
3. Complete disorientation with withdrawal from social interaction
occurs in late stages.
3. A nurse is caring for a client who has dementia. When performing a
Mental Status Examination (MSE), the nurse should include which of
the following data? (Select all that apply.)
A. Ability to perform calculations
B. Level of consciousness
C. Recall ability
D. Long-term memory
E. Level of orientation
Answer: A, C, E
Rationale:
1. Evaluating the client's ability to perform calculations is an included
component of an MSE.
2. Identifying the client's ability to recall a list of objects or words is an
included component of an MSE.
3. Determining the client's level of orientation is an included
component of an MSE.
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4. Level of consciousness and long-term memory are not standard
components of an MSE.
4. A nurse is caring for a client who has dementia due to Alzheimer's
disease and was admitted to a long-term care facility following the
death of her partner of 40 years. The client states, "I want to go home;
my husband is waiting for me to cook dinner." Which of the following
responses by the nurse is appropriate?
A. "This is where you live now."
B. "This is a safer place for you to live."
C. "Tell me what you like to cook for dinner."
D. "Your family said there is no one to care for you at home."
Answer: C. "Tell me what you like to cook for dinner."
Rationale:
1. The nurse is demonstrating validation therapy by asking the client to
talk about the areas that concern her.
2. The nurse could continue the conversation by discussing how much
the client misses her home and partner.
3. Validation therapy helps clients who have cognitive disorders discuss
their feelings about past events and people.
5. A nurse on a long-term care unit is creating a plan of care for a
client who has Alzheimer's disease. Which of the following
interventions should the nurse include in the plan?
A. Rotate assignment of daily caregivers.
B. Provide an activity schedule that changes from day to day.
C. Limit time for the client to perform activities.
D. Talk the client through tasks one step at a time.
Answer: D. Talk the client through tasks one step at a time.
Rationale:
1. Talking the client through tasks one step at a time minimizes
confusion.
2. This approach promotes independence.
3. Decreasing the client's anxiety level is an additional benefit.
6. A nurse is caring for a client who is cognitively impaired. Which of
the following rooms will provide a therapeutic environment for this
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client?
A. A room adjacent to the nursing station
B. A room without a window
C. A room with dim lighting
D. A room containing personal belongings
Answer: D. A room containing personal belongings
Rationale:
1. A room that contains several of the client's personal belongings
assists in maintaining personal identity.
2. Familiar items provide a therapeutic environment.
7. The family of an older adult client brings him to the emergency
department after finding him wandering outside. During the initial
assessment, the nurse notes that the client flinches when she palpates
his abdomen yet responds to questions only by nodding and smiling.
Which of the following factors should the nurse identify as a likely
explanation for the client's behavior?
A. He is hard of hearing.
B. Pain.
C. Confusion.
D. Language barrier.
Answer: C. Confusion.
Rationale:
1. The client was manifesting signs of confusion before coming to the
emergency department.
2. He currently seems unable to understand or respond to speech.
3. The nurse should determine that the client has confusion.
8. A nurse is performing a mental status examination (MSE) on a client
who has a new diagnosis of dementia. Which of the following
components should the nurse include? (Select all that apply.)
A. Grooming
B. Long-term memory
C. Support systems
D. Affect
E. Presence of pain
NR 341 Complex Adult Health
Exam 1 | Questions with
Rationalized Answers | 100%
Guaranteed Pass | Advanced
Medical-Surgical & NCLEX-RN®
Exam Structure:
Subject: Complex Adult Health (NR 341)
Source: NR 341 Complex Adult Health Exam 1
Format: Questions and Verified Answers with Rationales
1. A nurse is caring for a group of older adult clients. Which of the
following manifestations indicates one of the clients is experiencing
delirium?
A. A client wants to know the current time while there is a clock on the wall.
B. A client attempts to climb out of bed and repeatedly states she must get
home.
C. A client requests extra blankets when the thermostat in the room
indicates 25.6°C (78°F).
D. A client refuses to get out of bed and has no motivation to attend to daily
hygiene.
Answer: B. A client attempts to climb out of bed and repeatedly states she
must get home.
Rationale:
1. Delirium is characterized by a change in cognition that occurs over a
short period of time.
2. It results from a secondary physiological condition (e.g., infection,
surgery, prolonged hospitalization, hypoxia, fever, medications).
, 2|Page
3. Delirium frequently progresses in the evening hours and is
sometimes called "sundown syndrome."
4. Manifestations include alterations in memory, agitation, restlessness,
illusions, or hallucinations.
2. A community health nurse is providing teaching to the family of a
client who has primary dementia. Which of the following
manifestations should the nurse tell the family to expect?
A. Decreased auditory and visual acuity.
B. Decreased display of emotion.
C. Personality traits that are opposite of original traits.
D. Forgetfulness gradually progressing to disorientation.
Answer: D. Forgetfulness gradually progressing to disorientation.
Rationale:
1. Dementia usually appears first as forgetfulness.
2. Loss of functioning progresses slowly from impaired language skills
and difficulty with ordinary daily activities to severe memory loss.
3. Complete disorientation with withdrawal from social interaction
occurs in late stages.
3. A nurse is caring for a client who has dementia. When performing a
Mental Status Examination (MSE), the nurse should include which of
the following data? (Select all that apply.)
A. Ability to perform calculations
B. Level of consciousness
C. Recall ability
D. Long-term memory
E. Level of orientation
Answer: A, C, E
Rationale:
1. Evaluating the client's ability to perform calculations is an included
component of an MSE.
2. Identifying the client's ability to recall a list of objects or words is an
included component of an MSE.
3. Determining the client's level of orientation is an included
component of an MSE.
, 3|Page
4. Level of consciousness and long-term memory are not standard
components of an MSE.
4. A nurse is caring for a client who has dementia due to Alzheimer's
disease and was admitted to a long-term care facility following the
death of her partner of 40 years. The client states, "I want to go home;
my husband is waiting for me to cook dinner." Which of the following
responses by the nurse is appropriate?
A. "This is where you live now."
B. "This is a safer place for you to live."
C. "Tell me what you like to cook for dinner."
D. "Your family said there is no one to care for you at home."
Answer: C. "Tell me what you like to cook for dinner."
Rationale:
1. The nurse is demonstrating validation therapy by asking the client to
talk about the areas that concern her.
2. The nurse could continue the conversation by discussing how much
the client misses her home and partner.
3. Validation therapy helps clients who have cognitive disorders discuss
their feelings about past events and people.
5. A nurse on a long-term care unit is creating a plan of care for a
client who has Alzheimer's disease. Which of the following
interventions should the nurse include in the plan?
A. Rotate assignment of daily caregivers.
B. Provide an activity schedule that changes from day to day.
C. Limit time for the client to perform activities.
D. Talk the client through tasks one step at a time.
Answer: D. Talk the client through tasks one step at a time.
Rationale:
1. Talking the client through tasks one step at a time minimizes
confusion.
2. This approach promotes independence.
3. Decreasing the client's anxiety level is an additional benefit.
6. A nurse is caring for a client who is cognitively impaired. Which of
the following rooms will provide a therapeutic environment for this
, 4|Page
client?
A. A room adjacent to the nursing station
B. A room without a window
C. A room with dim lighting
D. A room containing personal belongings
Answer: D. A room containing personal belongings
Rationale:
1. A room that contains several of the client's personal belongings
assists in maintaining personal identity.
2. Familiar items provide a therapeutic environment.
7. The family of an older adult client brings him to the emergency
department after finding him wandering outside. During the initial
assessment, the nurse notes that the client flinches when she palpates
his abdomen yet responds to questions only by nodding and smiling.
Which of the following factors should the nurse identify as a likely
explanation for the client's behavior?
A. He is hard of hearing.
B. Pain.
C. Confusion.
D. Language barrier.
Answer: C. Confusion.
Rationale:
1. The client was manifesting signs of confusion before coming to the
emergency department.
2. He currently seems unable to understand or respond to speech.
3. The nurse should determine that the client has confusion.
8. A nurse is performing a mental status examination (MSE) on a client
who has a new diagnosis of dementia. Which of the following
components should the nurse include? (Select all that apply.)
A. Grooming
B. Long-term memory
C. Support systems
D. Affect
E. Presence of pain
