A client who recently immigrated to the United States from Korea is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after the client's admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action is most appropriate at this time?
A. Documenting that the client is resting quietly and denies pain B. Calling a family member to obtain information about the client C. Giving the client the ordered as-needed pain medication D. Checking vital signs and assessing for nonverbal indications of pain
Checking vital signs and assessing for nonverbal indications of pain-rationale: the nurse should consider the possibility that the client didnt understand the question or has been conditioned culturally not to complain openly of pain. checking vital signs and assessing for nonverbal indications of pain help the nurse determine whether the client is in pain. accepting the clients response without question or further assessment may result in inadequate intervention. calling the family or giving pain medication isnt warranted at this time because the client denies pain and the nurse needs to obtain more information.client needs category: physiological integrityclient needs subcategory: basic care and comfortcognitive level: applicationreference: taylor, c., et al. fundamentals of nursing: the art and science of nursing care, 6th ed. philadelphia: lippincott williams & wilkins, 2008, p. 1375.