Clinical Practice / Delirium vs. dementia
Delirium vs. Dementia: 10 PMHNP Practice Questions
Practice recognizing acute change, interpreting assessment findings, and choosing a safe next step. Read each case, choose one best answer, then expand the explanation.
Independent educational content for PMHNP board preparation, not individualized medical advice. All cases are fictional and original; these are not official ANCC questions. This resource is not affiliated with or endorsed by ANCC and does not guarantee exam results. Suspected delirium requires urgent clinical assessment.
Need the framework first? Read the delirium vs. dementia guide.
1. The Unusually Quiet Morning
An 82-year-old long-term-care resident usually chats during breakfast. Today the resident is sleepy, gives delayed answers, and repeatedly loses track of the question. Staff report the change began overnight. Which action is most appropriate?
- Arrange comprehensive neuropsychological testing for a possible chronic cognitive disorder
- Arrange urgent medical assessment for possible hypoactive delirium
- Begin treatment for late-life depression and repeat the interview after mood improves
- Repeat the mental status examination at the scheduled monthly visit
Show answer and rationale for question 1
B. Arrange urgent medical assessment for possible hypoactive delirium.
Acute inattention and altered alertness require a medical assessment even without agitation. Hypoactive delirium can be easily overlooked.
Why the Other Choices Do Not Fit
- A delays evaluation of an acute change; cognitive testing can follow stabilization.
- C assumes a mood disorder without explaining the overnight change.
- D defers assessment of a new potentially urgent change until a routine follow-up.
2. What Makes the Decline Clinically Important?
A 76-year-old has gradually increasing difficulty planning meals, paying bills, and managing medications over 18 months. The daughter now manages bills and medications because the patient can no longer do so safely. The patient is alert, follows the interview, and has no recent acute change. Which conclusion is best supported?
- Reassure the family that these changes are consistent with normal cognitive aging
- Exclude a neurocognitive disorder because alertness and attention are preserved
- Evaluate the functional decline for a neurocognitive disorder and other contributing causes
- Diagnose Alzheimer’s disease because several everyday tasks have become difficult
Show answer and rationale for question 2
C. Evaluate the functional decline for a neurocognitive disorder and other contributing causes.
Dementia affects everyday functioning and is not limited to memory. The history supports further diagnostic evaluation, not a subtype diagnosis from this vignette alone.
Why the Other Choices Do Not Fit
- A minimizes a functional decline that is not normal aging.
- B confuses alertness with intact cognition.
- D skips the differential, examination, and evaluation for contributing causes.
3. The Medication Timeline
A previously independent 71-year-old develops fluctuating attention after several nights of an over-the-counter sleep aid containing diphenhydramine. Which additional history is most useful during the urgent evaluation?
- A full timeline of prescribed, nonprescription, and recently stopped medicines and substances
- Psychiatric prescriptions only, because nonprescription products are less diagnostically relevant
- Whether a relative had Alzheimer’s disease, before reviewing current exposures
- The patient’s lifelong personality before reviewing recent physical symptoms
Show answer and rationale for question 3
A. A full timeline of prescribed, nonprescription, and recently stopped medicines and substances.
A medication contribution is plausible, but the evaluator must still assess for other causes. New products, dose changes, missed drugs, and withdrawal can change the differential.
Why the Other Choices Do Not Fit
- B misses nonprescription and nonpsychiatric contributors.
- C can inform a later cognitive history but does not address the acute exposure.
- D delays the cause-directed assessment and does not explain a new fluctuating presentation.
4. The Missing Baseline
An emergency clinician sees a disoriented patient with known dementia. The patient’s examination is inconsistent across the visit. Which collateral question best clarifies whether delirium may be superimposed?
- How often did the patient forget names during the years before hospitalization?
- Which relatives developed progressive memory problems and at what ages?
- What techniques usually calm the patient when unfamiliar staff approach?
- What changed from the patient’s usual attention and alertness, and when?
Show answer and rationale for question 4
D. What changed from the patient’s usual attention and alertness, and when?
A reliable baseline and timing distinguish a new layer of dysfunction from the established chronic pattern. Dementia and delirium can coexist.
Why the Other Choices Do Not Fit
- A establishes neither recent change nor severity.
- B is relevant background but not the immediate comparison.
- C may help with supportive care but does not establish the timing of cognitive change.
5. The Urine Result
An 86-year-old with cognitive impairment has delirium and a urine culture showing bacteriuria. There are no local urinary symptoms, fever, or hemodynamic instability. What is the best interpretation?
- Start antibiotics because bacteriuria identifies the most likely cause of the delirium
- Assess other causes, observe carefully, and avoid antibiotics without evidence of symptomatic infection
- Limit further infection evaluation because a normal temperature makes infection unlikely
- Repeat the urine culture before investigating any nonurinary cause
Show answer and rationale for question 5
B. Assess other causes, observe carefully, and avoid antibiotics without evidence of symptomatic infection.
IDSA advises this approach for the described situation. Bacteriuria may be incidental; treating it without evidence of symptomatic infection may cause harm.
Why the Other Choices Do Not Fit
- A mistakes a urine finding for a causal diagnosis.
- C overgeneralizes; clinical assessment and reassessment remain necessary.
- D delays evaluation of other possible causes and still cannot establish symptomatic UTI from the culture alone.
6. What the 4AT Can Tell You
A patient with an acute change in behavior has a 4AT score of 5. Which statement accurately describes the next step?
- Classify the finding as dementia and begin a long-term cognitive treatment plan
- Treat the 4AT result as a final diagnosis without further clinical assessment
- Assess clinically for possible delirium, then identify and address its underlying contributors
- Repeat a MoCA in six months before making any clinical decision
Show answer and rationale for question 6
C. Assess clinically for possible delirium, then identify and address its underlying contributors.
A 4AT score of 4 or more suggests possible delirium, with or without cognitive impairment. It supports assessment; it does not replace clinical diagnosis.
Why the Other Choices Do Not Fit
- A makes a dementia diagnosis from an acute screening result that cannot establish it.
- B overstates what the tool establishes.
- D delays care for an acute presentation.
Source: 4AT: clinical user guide
7. The Haloperidol Safety Check
A patient with Parkinson’s disease develops delirium during hospitalization and becomes severely distressed despite de-escalation. Haloperidol is proposed because it has a relatively low anticholinergic burden. What is the most appropriate response?
- Give a low dose because its limited anticholinergic effects make it the preferred choice
- Choose the oral formulation and monitor for stiffness after the first dose
- Treat agitation first and defer review of medical contributors until the patient is calm
- Withhold haloperidol and request individualized management that accounts for the patient’s neurologic risk
Show answer and rationale for question 7
D. Withhold haloperidol and request individualized management that accounts for the patient’s neurologic risk.
The U.S. haloperidol label contraindicates use in Parkinson’s disease. A favorable feature of one drug does not override a patient-specific contraindication. Continue cause-directed care.
Why the Other Choices Do Not Fit
- A confuses low anticholinergic activity with overall safety.
- B ignores a known contraindication rather than managing risk before exposure.
- C delays cause-directed evaluation; symptom control and medical assessment should proceed together when needed.
8. When the Exception Matters
A hospitalized adult develops tremor, autonomic hyperactivity, inattention, disorientation, and visual hallucinations after abrupt cessation of heavy daily alcohol use. The team diagnoses alcohol-withdrawal delirium. Which treatment principle is most appropriate?
- Use antipsychotic monotherapy and reassess after hallucinations and agitation settle
- Avoid all sedatives and manage withdrawal with reorientation and reassurance only
- Start benzodiazepine-based treatment under a medical withdrawal protocol with close monitoring
- Use clonidine alone for autonomic symptoms and reassess when the pulse improves
Show answer and rationale for question 8
C. Start benzodiazepine-based treatment under a medical withdrawal protocol with close monitoring.
ASAM recommends benzodiazepines as first-line agents for alcohol-withdrawal delirium. This is a cause-specific exception to avoiding routine benzodiazepine sedation in other delirium presentations.
Why the Other Choices Do Not Fit
- A does not adequately treat the withdrawal syndrome; antipsychotics may be adjuncts in selected situations.
- B omits the indicated cause-specific pharmacologic treatment for withdrawal delirium.
- D treats autonomic signs without adequately treating withdrawal delirium; clonidine alone is not appropriate.
Source: ASAM Clinical Practice Guideline on Alcohol Withdrawal Management
9. A Better Supportive Plan
A hospitalized patient with delirium repeatedly mishears staff and becomes frightened at night. The patient’s hearing aids and glasses are at home. Which addition best supports the ongoing medical treatment?
- Restore sensory aids, provide gentle orientation, and support a familiar sleep-friendly environment
- Limit daytime activity and use overnight checks to prevent prolonged sleep
- Add a nightly sedative before changing sensory or environmental supports
- Limit familiar visitors until confusion resolves to reduce the number of stimuli
Show answer and rationale for question 9
A. Restore sensory aids, provide gentle orientation, and support a familiar sleep-friendly environment.
Practical support can reduce disorientation and distress while the team treats the cause. Basic sensory needs are part of care, not an optional extra.
Why the Other Choices Do Not Fit
- B disrupts the sleep-wake cycle.
- C substitutes sedation for assessment and supportive measures.
- D removes potentially helpful familiar support without an individualized reason.
10. When Recovery Is Incomplete
A patient’s dehydration has been treated, but attention still fluctuates several days later. What is the most appropriate interpretation?
- Reassess ongoing contributors, continue supportive care, and plan follow-up of cognition
- Exclude delirium because symptoms persisted after a reversible cause was treated
- Diagnose Alzheimer’s disease because the cognitive symptoms have lasted several days
- Stop further investigation and wait for all symptoms to resolve on their own
Show answer and rationale for question 10
A. Reassess ongoing contributors, continue supportive care, and plan follow-up of cognition.
Delirium may persist, and several contributors or underlying cognitive impairment may be present. Reassessment is more appropriate than a recovery guarantee or premature permanent label.
Why the Other Choices Do Not Fit
- B ignores the variable course of delirium.
- C assigns a subtype and irreversibility without sufficient evidence.
- D assumes that identifying one contributor excludes all others.
Review the Reasoning
For each missed item, identify the clue you underweighted: time course, attention, baseline, functional change, or a safety consideration. Then explain why your chosen distractor was less appropriate.
Return to the guide or choose another Clinical Practice topic.
Sources and Further Reading
- NICE CG103: delirium recommendations
- IDSA: asymptomatic bacteriuria guideline
- MHRA: haloperidol safety in older adults with delirium
- U.S. haloperidol prescribing information
- 4AT: clinical user guide
- National Institute on Aging: what is dementia?
- ASAM Clinical Practice Guideline on Alcohol Withdrawal Management
Sources checked October 21, 2026. Apply current local protocols, product-specific labeling, and the patient’s clinical context.
Keep the Big Picture in Reach
The PMHNP Playbook gives you a concise foundation to connect with the reasoning in this guide.