A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?

Assessment of a child with Pertussis focuses on identifying characteristic stages of illness, especially the paroxysmal stage where severe coughing fits occur. Pertussis is a highly contagious respiratory infection that progresses from a mild catarrhal phase to intense coughing spells followed by inspiratory “whooping.” The disease is particularly dangerous in children due to risk of hypoxia, vomiting after coughing, and exhaustion. Recognizing hallmark respiratory manifestations is essential for timely isolation and treatment.

Rationale:
A. A beefy red tongue is more commonly associated with conditions such as scarlet fever or Kawasaki disease. It is not a typical finding in pertussis. Pertussis primarily affects the respiratory tract rather than causing characteristic oral mucosal changes.

B. Koplik spots are a classic early sign of measles and appear as small white lesions on the buccal mucosa. These are not associated with pertussis infection. Their presence would indicate a different viral illness affecting the respiratory and mucosal surfaces.

C. Peeling of the hands and feet is commonly associated with Kawasaki disease, occurring in the subacute phase. It is not a feature of pertussis, which does not involve systemic vasculitis or desquamation of extremities. This finding would suggest an alternative diagnosis.

D. Paroxysmal coughing is the hallmark manifestation of Pertussis, characterized by repeated, forceful coughing spells that may end in a high-pitched inspiratory “whoop.” These episodes can lead to vomiting, exhaustion, and hypoxia, especially in young children. This is the most characteristic and expected clinical finding.

Major depressive disorder can significantly impair mood, cognition, motivation, and behavior. During the early phase of treatment with antidepressants, clients may begin to experience increased energy before mood improves, which can elevate the risk of suicidal behavior. Nurses must prioritize assessment of safety-related statements that indicate possible suicidal ideation or preparatory actions. Early identification and intervention are critical to prevent self-harm and ensure client safety.

Rationale:
A. Loss of interest in sexual intercourse is a common symptom of major depressive disorder and can also be a side effect of antidepressant therapy. While it may affect quality of life, it is not an immediate safety concern. This finding does not indicate imminent risk of harm.

B. Feelings of guilt about family impact are consistent with depressive cognition and distorted thinking patterns. Although emotionally significant, this statement reflects typical depressive symptoms rather than immediate risk of self-harm. It requires monitoring but is not the highest priority.

C. Low energy and difficulty getting out of bed are hallmark symptoms of depression related to psychomotor retardation. While these symptoms affect functioning, they do not indicate immediate danger to the client’s life. Supportive care and medication adherence are appropriate interventions.

D. Giving away belongings is a critical warning sign of suicidal ideation and preparatory behavior. In clients with conditions such as Major depressive disorder, this action may indicate planning for self-harm or suicide. This statement requires immediate safety assessment, escalation, and intervention to protect the client.