Medical Surgical Dementia vs Delirium #5

Question

An elderly, long- term care client suddenly becomes confused, not knowing where they are and asking for their mother (who has been dead for 40-years). Cranial nerve VII intact, PERRLA present, speech is clear, and grips are equal at 4+. Which condition does the registered nurse suspect?

Answers

  1. Stroke
    • Rationale:

      This answer is not correct because there are no common and obvious stroke symptoms. The neuromuscular exam reveals that the cranial nerve VII (smile) is intact, pupils equal, round, reactive to light, and accommodative, clear speech, and equal, and strong grips for the client’s age. Therefore, stroke doesn’t appear to be present at this time.

  2. Bell’s palsy
    • Rationale:

      This answer is not correct because the cranial nerve VII (smile) is intact. This means the nurse elicited the client to smile and the smile did not indicate any droop. This is an obvious symptom associated with Bell’s palsy and stroke so both of those conditions are ruled out. Confusion from delirium occurs quickly as a result of an infection or another underlying cause.

  3. Delirium
    • Rationale:

      This answer is correct because confusion from delirium occurs quickly as a result of an infection or another underlying cause. Although the underlying cause has not been identified, other conditions, such as stroke and Bell’s palsy, have been ruled out with the neuromuscular assessment. Bell’s palsy does not have confusion associated with it, but would have the facial droop so assessment of the facial nerve rules both the stroke and Bell’s palsy out.

  4. Dementia
    • Rationale:

      This answer is not correct because confusion and disorientation associated with dementia occurs gradually, over a longer period of time. Confusion from delirium occurs quickly as a result of an infection or another underlying cause.

Overview

Delirium occurs suddenly and presents with confusion. The other assessment findings (cranial nerve VII intact, PERRLA present, speech is clear, and grips are equal at 4+ are normal.

Explanation

Learning Outcomes

Confusion from delirium occurs quickly as a result of an infection or another underlying cause. Delirium is treatable, by treating the cause of the delirium. The client is elderly, making the client more susceptible to delirium from an infection (UTI, pneumonia) or from drug interactions or reactions, due to the aging liver and kidneys. The client with otherwise normal neuromuscular assessment, such as cranial nerve VII (smile) is intact, pupils equal, round, reactive to light, and accommodative, clear speech, and equal, and strong grips for the client’s age, helps the nurse confirm there are no common and obvious stroke symptoms. Since the facial nerve is intact, there is no Bell’s palsy symptoms. Since the confusion occurred quickly, dementia is not suspected.

Test Taking Tip

Time matters here and makes all the difference between delirium and dementia. It also makes ruling out more emergent conditions, such as a stroke and head injury through assessment an important nursing action.

Video Rationale