A nurse on a mental health unit is caring for a client who is in wrist restraints following a violent outburst. Which of the following actions should the nurse take?

Pertussis, also known as whooping cough, is a highly contagious respiratory infection caused by Bordetella pertussis. It is characterized by inflammation of the upper respiratory tract leading to severe, uncontrollable coughing episodes. The illness typically progresses through stages, with the paroxysmal stage being most clinically distinctive. Recognition of hallmark symptoms is essential for early diagnosis, isolation, and prevention of transmission, especially in pediatric populations.

Rationale:
A. Koplik spots are small bluish-white lesions on an erythematous base found on the buccal mucosa and are a classic early sign of measles (rubeola), not pertussis. Their presence indicates a viral exanthem rather than a bacterial respiratory infection. They are not associated with pertussis.

B. A beefy, red tongue is commonly associated with conditions such as scarlet fever or vitamin deficiencies. It reflects mucosal inflammation or systemic infection affecting the oral cavity. This finding is not characteristic of pertussis, which primarily affects the respiratory tract rather than oral mucosa.

C. Peeling of the hands and feet is typically seen in conditions such as Kawasaki disease, where vasculitis leads to desquamation during the subacute phase. This manifestation is unrelated to pertussis, which does not involve systemic vasculitis or skin desquamation as a primary feature.

D. A paroxysmal cough is the hallmark manifestation of pertussis, characterized by sudden, intense coughing fits that may end with a whooping sound during inspiration. These episodes can be followed by vomiting or exhaustion due to increased intrathoracic pressure. This symptom results from toxin-mediated damage to the respiratory epithelium caused by Bordetella pertussis.

This case focuses on identifying risk factors contributing to delirium in an older adult postoperative ICU client. Delirium is commonly triggered by acute illness, infection, surgery, and underlying chronic conditions that affect brain resilience. Sensory deficits and environmental changes also significantly increase susceptibility. Recognizing predisposing and precipitating factors is essential for early prevention and management of acute cognitive decline.

Rationale for correct choices:

• Older adult status with recent surgery, ICU admission, fever, hypotension, and hip arthroplasty
Advanced age is a major risk factor for delirium due to decreased physiological reserve and brain vulnerability. Recent major surgery such as total hip arthroplasty increases risk due to anesthesia effects, pain, and immobility. The presence of fever and hypotension suggests systemic infection (likely sepsis), which is a strong precipitating factor for delirium. ICU admission further increases risk due to sleep disruption, invasive monitoring, and environmental stressors.

• Past medical history (hypertension, congestive heart failure, Parkinson’s disease): Chronic neurological and cardiovascular conditions increase vulnerability to altered cerebral perfusion and cognitive dysfunction. Parkinson’s disease specifically affects dopamine pathways, making patients more susceptible to confusion and hallucinations. Congestive heart failure may reduce oxygen delivery to the brain, contributing to cognitive changes. These conditions collectively lower the threshold for delirium development.

• Social history (visual loss, no glasses, hearing impairment): Sensory deprivation is a major modifiable risk factor for delirium. Visual and hearing impairments reduce environmental awareness and increase misinterpretation of stimuli. Not having glasses further worsens disorientation and confusion in a hospital setting. Even with hearing aids, older adults may still experience impaired processing, increasing vulnerability to cognitive decline.

Rationale for incorrect finding:

• Client is alert and oriented to person, place, and time: At baseline, this indicates intact cognitive function rather than a risk factor. While important for comparison, it does not contribute to delirium development. This statement reflects the client’s prior stable mental status before acute changes occurred.