A nurse is assisting with the care of a client who is receiving a spinal epidural to treat a herniated disc.

Which of the following findings should the nurse identify as an indicator of unrelieved pain?

The AIMS is specifically designed to assess for the presence and severity of abnormal involuntary movements, which can be a side effect of long-term antipsychotic medication use, including tardive dyskinesia. It consists of a series of standardized movements and observations that assess different body regions for abnormal movements. The nurse can use this tool to monitor the client's movements and identify any signs of tardive dyskinesia.

A. Mental Status Examination (MSE): The MSE is a comprehensive assessment of a client's mental status, including their cognition, mood, and thought processes. While the MSE is an important tool in assessing overall mental health, it is not specific to tardive dyskinesia.
C. Patient Health Questionnaire-9 (PHQ-9): The PHQ-9 is a screening tool for depression that assesses the severity of depressive symptoms. While depression can be a comorbidity in individuals with schizophrenia, the PHQ-9 does not directly assess for tardive dyskinesia.
D. Brief Psychiatric Rating Scale (BPRS): The BPRS is a rating scale used to assess the severity of psychiatric symptoms in individuals with mental disorders. While it is useful in evaluating overall symptomatology in schizophrenia, it does not specifically target tardive dyskinesia.

Based on the given information, the nurse should take the following actions in preparation for surgery:

• Obtain a complete blood count: This is important to assess the client's hemoglobin, hematocrit, and other blood parameters before surgery.
• Prepare the client for insertion of an 18-gauge peripheral IV prior to surgery: Adequate IV access is necessary for the administration of fluids and medications during and after surgery.
• Administer Rh, D immune globulin prior to surgery: This action is indicated if the client is Rh-negative and there is a possibility of fetal-maternal blood mixing during the termination of pregnancy. Rh, D immune globulin is given to prevent sensitization to

Rh-positive blood.

• Verify consent form is signed by the client: Ensuring that the client has provided informed consent is essential before proceeding with any surgical intervention.
• Remind the client to be NPO (nothing by mouth) prior to surgery: It is important for the client to have an empty stomach to reduce the risk of aspiration during anesthesia.

The following actions are not indicated based on the given information:

• Explaining the surgical procedure to the client: Although it is important for the client to have an understanding of the procedure, this is typically done by the surgeon rather than the nurse.
• Assisting with administration of AB positive blood products if needed: There is no indication of the need for blood products based on the information provided. Blood product administration would be determined based on the client's specific condition and surgical requirements.