,NSG 2600 Final Exam Adult Health Nursing I Questions And Answers
2026/2027 South College
Q1. A 76-year-old client is admitted for evaluation of increasing
weakness and reduced appetite. During the initial assessment, the
nurse observes that the client is suddenly unable to maintain
attention, repeatedly misidentifies the hospital environment, and
has a fluctuating level of alertness. The family reports that these
changes developed over the previous 24 hours. Which interpretation
is most appropriate?
A) The findings are normal manifestations of advanced age.
B) The findings confirm an irreversible neurodegenerative condition.
C) Acute delirium should be suspected, and reversible physiological causes
require prompt investigation.
D) The changes indicate uncomplicated anxiety that requires no further
assessment.
Correct Answer: C) Acute delirium should be suspected, and reversible
physiological causes require prompt investigation.
Rationale: Delirium is characterized by an acute disturbance in attention and
awareness that fluctuates over time. Common causes include infection,
hypoxemia, metabolic disturbances, dehydration, medication effects, and
organ dysfunction. Unlike chronic dementia, delirium develops over a short
period and may improve when precipitating factors are identified and
treated.
Q2. A 64-year-old client with diabetes and peripheral neuropathy
reports no pain despite having a deep plantar foot ulcer. The wound
has surrounding redness and moderate drainage. Which assessment
principle is most important?
A) Absence of pain reliably excludes serious tissue injury.
B) Wound severity should be determined only by the amount of reported
discomfort.
C) Reduced sensation indicates that wound infection cannot occur.
D) Loss of protective sensation may conceal significant injury, making direct
wound, vascular, and infection assessment essential.
,Correct Answer: D) Loss of protective sensation may conceal significant
injury, making direct wound, vascular, and infection assessment essential.
Rationale: Peripheral neuropathy reduces the ability to detect trauma,
pressure, and infection-related discomfort. Serious diabetic foot
complications may therefore occur without substantial pain. Assessment
should address wound depth, drainage, surrounding tissue, protective
sensation, perfusion, and possible bone involvement.
Q3. A 59-year-old client reports dizziness when standing. Blood
pressure decreases from 144/86 mmHg while supine to 112/70
mmHg three minutes after standing. Heart rate increases from 76 to
104 beats/minute. Which nursing intervention is most appropriate?
A) Assess for orthostatic hypotension, medication effects, and volume
depletion while implementing fall precautions.
B) Encourage the client to stand quickly several times.
C) Administer additional antihypertensive medication without further
assessment.
D) Explain that the findings represent normal cardiovascular function.
Correct Answer: A) Assess for orthostatic hypotension, medication effects,
and volume depletion while implementing fall precautions.
Rationale: A decrease in systolic blood pressure of at least 20 mmHg or
diastolic pressure of at least 10 mmHg after standing supports orthostatic
hypotension. Symptoms may result from dehydration, autonomic
dysfunction, or medications. Fall precautions and evaluation of underlying
causes reduce the risk of injury.
Q4. A hospitalized 81-year-old client with mild cognitive impairment
is at increased risk of delirium. Which preventive nursing strategy is
most appropriate?
A) Limit all family contact.
B) Promote orientation, mobilization, adequate hydration, sleep hygiene, and
use of hearing or visual aids.
C) Administer sedative medications routinely.
D) Maintain continuous bed rest with minimal environmental stimulation.
, Correct Answer: B) Promote orientation, mobilization, adequate hydration,
sleep hygiene, and use of hearing or visual aids.
Rationale: Multicomponent nonpharmacological interventions can reduce
delirium risk in vulnerable hospitalized adults. Orientation, early mobility,
correction of sensory deficits, adequate nutrition and hydration, and sleep
promotion address common precipitating factors. Unnecessary restraints and
sedatives can worsen confusion.
Q5. A 67-year-old client with chronic kidney disease takes several
prescribed medications and herbal supplements. The client develops
unexpected bruising after starting a new over-the-counter product.
Which nursing action best supports medication safety?
A) Discontinue all prescribed medications permanently.
B) Assume herbal supplements cannot affect coagulation.
C) Obtain a complete medication and supplement history, evaluate
interactions, and notify the prescribing clinician of the new bleeding
symptoms.
D) Advise doubling the vitamin supplement dose.
Correct Answer: C) Obtain a complete medication and supplement history,
evaluate interactions, and notify the prescribing clinician of the new bleeding
symptoms.
Rationale: Herbal and nonprescription products can alter coagulation,
platelet activity, medication metabolism, and kidney function. Polypharmacy
increases the likelihood of adverse interactions. Medication reconciliation and
assessment of bleeding severity are essential.
Q6. A 55-year-old client with chronic obstructive pulmonary disease
is admitted for an acute illness. During the evening assessment, the
client becomes unusually quiet and increasingly somnolent.
Respiratory rate decreases from 28 to 11 breaths/minute despite
persistent accessory muscle use. Which interpretation is most
appropriate?
A) Respiratory function has improved because the rate decreased.
B) The findings confirm adequate alveolar ventilation.
C) The client is experiencing normal sleep onset.
2026/2027 South College
Q1. A 76-year-old client is admitted for evaluation of increasing
weakness and reduced appetite. During the initial assessment, the
nurse observes that the client is suddenly unable to maintain
attention, repeatedly misidentifies the hospital environment, and
has a fluctuating level of alertness. The family reports that these
changes developed over the previous 24 hours. Which interpretation
is most appropriate?
A) The findings are normal manifestations of advanced age.
B) The findings confirm an irreversible neurodegenerative condition.
C) Acute delirium should be suspected, and reversible physiological causes
require prompt investigation.
D) The changes indicate uncomplicated anxiety that requires no further
assessment.
Correct Answer: C) Acute delirium should be suspected, and reversible
physiological causes require prompt investigation.
Rationale: Delirium is characterized by an acute disturbance in attention and
awareness that fluctuates over time. Common causes include infection,
hypoxemia, metabolic disturbances, dehydration, medication effects, and
organ dysfunction. Unlike chronic dementia, delirium develops over a short
period and may improve when precipitating factors are identified and
treated.
Q2. A 64-year-old client with diabetes and peripheral neuropathy
reports no pain despite having a deep plantar foot ulcer. The wound
has surrounding redness and moderate drainage. Which assessment
principle is most important?
A) Absence of pain reliably excludes serious tissue injury.
B) Wound severity should be determined only by the amount of reported
discomfort.
C) Reduced sensation indicates that wound infection cannot occur.
D) Loss of protective sensation may conceal significant injury, making direct
wound, vascular, and infection assessment essential.
,Correct Answer: D) Loss of protective sensation may conceal significant
injury, making direct wound, vascular, and infection assessment essential.
Rationale: Peripheral neuropathy reduces the ability to detect trauma,
pressure, and infection-related discomfort. Serious diabetic foot
complications may therefore occur without substantial pain. Assessment
should address wound depth, drainage, surrounding tissue, protective
sensation, perfusion, and possible bone involvement.
Q3. A 59-year-old client reports dizziness when standing. Blood
pressure decreases from 144/86 mmHg while supine to 112/70
mmHg three minutes after standing. Heart rate increases from 76 to
104 beats/minute. Which nursing intervention is most appropriate?
A) Assess for orthostatic hypotension, medication effects, and volume
depletion while implementing fall precautions.
B) Encourage the client to stand quickly several times.
C) Administer additional antihypertensive medication without further
assessment.
D) Explain that the findings represent normal cardiovascular function.
Correct Answer: A) Assess for orthostatic hypotension, medication effects,
and volume depletion while implementing fall precautions.
Rationale: A decrease in systolic blood pressure of at least 20 mmHg or
diastolic pressure of at least 10 mmHg after standing supports orthostatic
hypotension. Symptoms may result from dehydration, autonomic
dysfunction, or medications. Fall precautions and evaluation of underlying
causes reduce the risk of injury.
Q4. A hospitalized 81-year-old client with mild cognitive impairment
is at increased risk of delirium. Which preventive nursing strategy is
most appropriate?
A) Limit all family contact.
B) Promote orientation, mobilization, adequate hydration, sleep hygiene, and
use of hearing or visual aids.
C) Administer sedative medications routinely.
D) Maintain continuous bed rest with minimal environmental stimulation.
, Correct Answer: B) Promote orientation, mobilization, adequate hydration,
sleep hygiene, and use of hearing or visual aids.
Rationale: Multicomponent nonpharmacological interventions can reduce
delirium risk in vulnerable hospitalized adults. Orientation, early mobility,
correction of sensory deficits, adequate nutrition and hydration, and sleep
promotion address common precipitating factors. Unnecessary restraints and
sedatives can worsen confusion.
Q5. A 67-year-old client with chronic kidney disease takes several
prescribed medications and herbal supplements. The client develops
unexpected bruising after starting a new over-the-counter product.
Which nursing action best supports medication safety?
A) Discontinue all prescribed medications permanently.
B) Assume herbal supplements cannot affect coagulation.
C) Obtain a complete medication and supplement history, evaluate
interactions, and notify the prescribing clinician of the new bleeding
symptoms.
D) Advise doubling the vitamin supplement dose.
Correct Answer: C) Obtain a complete medication and supplement history,
evaluate interactions, and notify the prescribing clinician of the new bleeding
symptoms.
Rationale: Herbal and nonprescription products can alter coagulation,
platelet activity, medication metabolism, and kidney function. Polypharmacy
increases the likelihood of adverse interactions. Medication reconciliation and
assessment of bleeding severity are essential.
Q6. A 55-year-old client with chronic obstructive pulmonary disease
is admitted for an acute illness. During the evening assessment, the
client becomes unusually quiet and increasingly somnolent.
Respiratory rate decreases from 28 to 11 breaths/minute despite
persistent accessory muscle use. Which interpretation is most
appropriate?
A) Respiratory function has improved because the rate decreased.
B) The findings confirm adequate alveolar ventilation.
C) The client is experiencing normal sleep onset.
