The title, objectives, and research methods are asynchronous.

This manuscript presents a well-designed, multi-site cross-sectional study that addresses a highly relevant and increasingly important issue in contemporary hospital nursing care. The authors provide robust empirical evidence demonstrating the high prevalence of cognitive impairment and delirium among hospitalised adults and clearly quantify the associated increase in fundamental care needs. The methodology is appropriate, transparently reported, and aligned with STROBE guidelines, and the analyses are rigorous and clinically meaningful. Overall, the study makes a valuable contribution to nursing and health services research.

The revised version has substantially improved in clarity, coherence, and justification of clinical importance. The authors have responded appropriately to reviewer comments by strengthening the background, clarifying ethical and methodological issues, and refining the presentation of results. The discussion effectively situates the findings within the existing literature and links them to key nursing concepts such as fundamental care, workforce capacity, and missed nursing care. Minor refinements to further emphasise the study’s novelty, international relevance, and implications for nursing education would enhance the manuscript’s impact but are not essential to the validity of the work.

Based on the overall quality, relevance, and scientific rigor of the manuscript, I recommend acceptance with minor editorial refinement. The suggested changes are limited to conceptual sharpening and language precision and do not require additional data or analyses. With these final refinements, the manuscript will be well positioned to inform nursing practice, workforce planning, and policy development at both national and international levels.