A nurse is assisting with the care of a client who has delirium. The client is disoriented and restless. Which of the following conditions should the nurse identify as a risk factor for delirium?

Choice A reason: Diminished pulses signal compromised circulation, a critical cast complication like compartment syndrome. This risks tissue necrosis or amputation if untreated, prioritizing it scientifically, as arterial flow disruption demands immediate intervention to preserve limb viability per vascular assessment standards.

Choice B reason: Ecchymosis suggests bruising, possibly from cast pressure, but isn’t immediately life-threatening like poor circulation. It’s a secondary concern, manageable later. Scientifically, it indicates trauma, not acute vascular emergency, ranking lower in urgency per cast complication protocols.

Choice C reason: Muscle spasms may indicate irritation or pressure, but they’re less urgent than absent pulses. Pain is common in casts, not always critical. Scientifically, this suggests nerve or muscle stress, not imminent tissue loss, making it a lower priority for immediate action.

Choice D reason: One fingerbreadth space is normal, preventing tightness, not a concern. It’s ideal fit, not a problem. Scientifically, this aligns with safe cast application, lacking urgency compared to circulatory threats, as it supports, rather than jeopardizes, limb health.

Choice A reason: A space heater 5 feet from a bed is relatively safe if unobstructed, not a leading fire cause. Scientifically, heaters rank lower than smoking, as ignition requires closer flammable contact, making this less statistically significant per fire safety data.

Choice B reason: Smoking in bed is a top cause of residential fires, as embers easily ignite bedding. Scientifically, NFPA data show it’s a leading ignition source due to direct fuel contact, causing rapid flame spread, making it a critical hazard to highlight.

Choice C reason: Leaving the stove on causes kitchen fires, but smoking surpasses it in residential fatalities. Scientifically, unattended cooking ranks high, yet smoking’s bedroom context increases risk of sleeping victims, amplifying danger per fire incidence studies.

Choice D reason: Lack of smoke detectors increases fire deaths, not ignition. It’s a detection failure, not a cause. Scientifically, this affects outcomes, not initiation, making it irrelevant to identifying the leading hazard source per fire safety causation statistics.