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?

Dementia is characterized by progressive memory impairment, including difficulty remembering recent events, names, and familiar faces. This memory loss can significantly impact the client's ability to perform daily tasks independently.

While dementia is typically a chronic and progressive condition, it is not uncommon for individuals with dementia to experience acute episodes of confusion, often referred to as "sundowning." These episodes tend to occur in the late afternoon or evening and can involve increased agitation, restlessness, and disorientation.

Illusions are perceptual distortions where a person misinterprets real sensory stimuli. In dementia, individuals may experience illusions, such as mistaking a coat hanging on a door for a person or misinterpreting shadows as threatening figures.

Catatonia, characterized by immobility and unresponsiveness, is not typically associated with dementia. It is more commonly seen in conditions such as schizophrenia or certain neurological disorders.

Provide the client with written information about advance directives: It is important for the nurse to educate the client about advance directives, their purpose, and how they can make informed decisions about their healthcare.

Instruct the client that an advance directive is a legal document and must be honored by care providers: The nurse should explain to the client that an advance directive is a legally binding document that guides healthcare decisions, and it must be respected and followed by healthcare providers.

Communicate advance directives status via the medical record and shift report: The nurse should ensure that the client's advance directives status is accurately documented in the medical record and communicated to other members of the healthcare team during shift handoffs. This helps ensure that the client's wishes are known and respected by all involved in their care.

Initiate a power of attorney for a healthcare document: The nurse can assist the client in initiating a power of attorney for a healthcare document if the client wishes to appoint someone as their healthcare proxy or agent. This document designates someone to make medical decisions on behalf of the client if they become unable to do so.

The other options listed are not appropriate or accurate in relation to the responsibilities of the nurse regarding advance directives:

• Document that the provider discussed do-not-resuscitate status with the client: While discussing do-not-resuscitate (DNR) status may be part of the advance care planning process, it is not directly related to advance directives as a whole.
• Inform the client that an advance directive discontinues further care: This statement is incorrect and misleading. An advance directive does not automatically discontinue care but rather guides the provision of care according to the client's wishes.