Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
35. A client, who fell 10 feet onto a concrete floor, presents to an emergency department. The client does not speak English. The correct action by a nurse to determine the severity of the client's pain would be to:
. Call for an interpreter.
. Note the client's facial expression.
. Observe the client's response to palpation.
. Use an illustrative pain scale.
Test-Taking Tip
Look for an assessment that is the client's own description, even though it is through a projective device.
Content Area: Adult Health, Pain Control; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Psychosocial Integrity/Cultural Diversity
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is incorrect because this may delay treatment, and the interpreter may not convey the client's pain as accurately as the client with a nonverbal pain scale. Answer 2 is incorrect because ethnic/cultural groups may "mask" the response to pain (e.g., by denial, rationalization as coping mechanisms). Answer 3 is incorrect because, depending on the culture, responding to pain may not be acceptable. Answer 4 is correct because pain scales, like the Oucher Scale, are accurate with many ethnic groups and languages.