{"id":7916,"date":"2025-10-06T00:01:37","date_gmt":"2025-10-06T08:01:37","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=7916"},"modified":"2025-10-02T12:55:54","modified_gmt":"2025-10-02T20:55:54","slug":"pance-question-of-the-day-confusion","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-confusion","title":{"rendered":"PANCE\u00ae Question of the Day: Confusion"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-confusion\/#The_correct_answer_to_todays_PANCE%C2%AE_Question_is%E2%80%A6\" >The correct answer to today&#8217;s PANCE\u00ae Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-confusion\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-confusion\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-confusion\/#Major_Takeaway\" >Major Takeaway<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-confusion\/#Want_to_learn_more_about_this_topic\" >Want to learn more about this topic?<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-confusion\/#References\" >References\u00a0<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>Prepare for the PANCE\u00ae with this challenging clinical scenario involving a 72-year-old woman showing signs of confusion.<\/em><\/strong> <strong><em>Which of the findings are consistent with delirium?<\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 72-year-old woman is brought by ambulance to the emergency department because of confusion. The patient is a professor at the local university and appeared confused during a lecture, prompting students to call an ambulance. Past medical history is significant for hypertension for which the patient takes amlodipine. The patient had two teeth extracted four days ago and has been taking oxycodone 5 mg orally every six hours for pain control. Vital signs are within normal limits. On physical examination, the patient appears confused. She has no focal neurologic deficits. Pupils are miotic but reactive. The lower abdomen is distended without tenderness to palpation. Rectal exam reveals hard, firm stool in the rectal vault. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Which of the following findings would be <em>most consistent<\/em> with a diagnosis of delirium?<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Inability to spell the word \u2018WORLD\u2019 backwards<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. History of increasing difficulty remembering words in her lectures for the past year<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Normal immediate recall of events just prior to the lecture<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Lack of interest in usually pleasurable activities for the past 3 months<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. One-year history of telling family and friends that a government agency is spying on her<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down to find the answer!&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;<\/em><\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Everybody loves Osmosis.org\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/kizbJZ9cdLg?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_PANCE%C2%AE_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s PANCE\u00ae Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Inability to spell the word \u2018WORLD\u2019 backwards<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Correct:<\/strong> See Main Explanation.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. History of increasing difficulty remembering words in her lectures for the past year<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> This would be more of an indication of dementia rather than delirium. Delirium has an acute and fluctuating course and develops over the course of hours to days. Dementia has a more chronic and progressive course.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Normal immediate recall of events just prior to the lecture<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Patients with dementia often have good immediate recall, while immediate recall is often impaired in patients with delirium.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Lack of interest in usually pleasurable activities for the past 3 months<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> This is more indicative of depression rather than delirium.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. One-year history of telling family and friends that a government agency is spying on her<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Patients with delirium may have delusions, but these typically exist for hours to days. Having ongoing delusion over months to years is more consistent with dementia or psychosis.\u00a0<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This patient who was prescribed opioid medication presents with confusion, miotic pupils, and a&nbsp; rectal exam that suggests constipation. These findings are consistent with opioid use and <strong>opioid intoxication causing<\/strong> <strong>delirium<\/strong>. <strong>Attention span<\/strong>, <strong>thought processes<\/strong>, and <strong>level of<\/strong> <strong>consciousness<\/strong> can all be altered in delirium. This patient&#8217;s mental status should be assessed, and focus should be on determining the patient\u2019s ability to <strong>sustain and shift attention<\/strong> appropriately. Being able to <strong>spell the word \u2018WORLD\u2019 backward <\/strong>(or serial 7s in non-English speakers) <strong>requires focused attention<\/strong>. Attention should also be assessed globally, which can be done while taking the history.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Delerium can often be missed in patients in the hospital. A widely used and validated scale to <strong>screen patients for delirium<\/strong> is the <strong>Confusion Assessment Method (CAM)<\/strong>, which includes 4 fundamental features of delirium: (1) acute onset and fluctuating course, (2) inattention, and either (3) disorganized thinking, or (4) altered level of consciousness.\u00a0\u00a0\u00a0\u00a0<\/p>\n\n\n\n<figure class=\"wp-block-image aligncenter size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"975\" height=\"534\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/10\/image_1f86e2.png\" alt=\"Confusion Assessment Method (CAM)\n(1) acute onset and fluctuating course, \n(2) inattention, and either \n(3) disorganized thinking, or \n(4) altered level of consciousness.\u00a0\u00a0\u00a0\u00a0\n\nCAM negative = Consider alternate diagnosis\n\nCAM positive = Delirium\" class=\"wp-image-7918\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/10\/image_1f86e2.png 975w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/10\/image_1f86e2.png?resize=300,164 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/10\/image_1f86e2.png?resize=768,421 768w\" sizes=\"auto, (max-width: 975px) 100vw, 975px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Delirium refers to an acute and fluctuating state of altered mental status where decreased attention is a hallmark feature. A global assessment of the patient\u2019s attention should be made, and questioning during the mental status exam should test patients\u2019 ability to maintain and shift attention appropriately.\u00a0<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Want_to_learn_more_about_this_topic\"><\/span>Want to learn more about this topic?<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Watch this Osmosis video:\u00a0<\/strong><a href=\"https:\/\/www.osmosis.org\/learn\/Delirium\">Delirium<\/a><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References\u00a0<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults (2015). American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults. <em>Journal of the American Geriatrics Society<\/em>, <em>63<\/em>(1), 142\u2013150.&nbsp;<\/li>\n\n\n\n<li>Devlin, J. W., Skrobik, Y., G\u00e9linas, C., Needham, D. M., Slooter, A. J. C., Pandharipande, P. P., Watson, P. L., Weinhouse, G. L., Nunnally, M. E., Rochwerg, B., Balas, M. C., van den Boogaard, M., Bosma, K. J., Brummel, N. E., Chanques, G., Denehy, L., Drouot, X., Fraser, G. L., Harris, J. E., Joffe, A. M., \u2026 Alhazzani, W. (2018). Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation\/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. <em>Critical care medicine<\/em>, <em>46<\/em>(9), e825\u2013e873.&nbsp;<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image size-large\"><a href=\"https:\/\/www.osmosis.org\/plans\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/03\/Blog_Display_Ads_MOBILE3_2023.png?w=700\" alt=\"\" class=\"wp-image-4433\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/03\/Blog_Display_Ads_MOBILE3_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/03\/Blog_Display_Ads_MOBILE3_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong><em>Want more PANCE\u00ae-style practice questions? Try Osmosis by Elsevier today! Access your&nbsp;<a href=\"http:\/\/osmosis.org\/create\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a>&nbsp;and discover why millions of current and future clinicians and caregivers love learning with us.<\/em><\/strong><a href=\"https:\/\/www.osmosis.org\/plans\/rn\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><a href=\"https:\/\/www.osmosis.org\/plans\/rn\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Review a clinical scenario highlighting features of delirium, assessment strategies, and distinctions from dementia and other cognitive disorders.<\/p>\n","protected":false},"author":204,"featured_media":7919,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[20,38,1371,37,1366],"tags":[1601,1455,1603,355,1602,1420,226,1600,1604,1599],"class_list":["post-7916","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-exam-prep","category-pance","category-pance-questions","category-pa","category-questions","tag-cam-screening","tag-cognitive-impairment","tag-confusion-assessment","tag-delirium","tag-elderly-patient-care","tag-icu-care","tag-mental-status-exam","tag-opioid-intoxication","tag-opioid-side-effects","tag-pance-prep"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - 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