The nurse is assessing a client's ability to speak and understand the English language. Which assessment findings are indicative of a language barrier? Select all that apply.

Question

1. The client answers with a minimal response.
2. The client's family member answers the questions.
3. The client does not make eye contact when spoken to.
4. The client moves away from the nurse when approached.
5. The client nods the head in agreement with everything the nurse says.

Answer 1

2. The client's family member answers the questions.
5. The client nods the head in agreement with everything the nurse says.

Explanation: 1. Minimally responding to an assessment question does not indicate that the client does not understand what is being asked or cannot communicate using the English language.
2. The client's family member answering the questions is indicative of a language barrier. The nurse's observation may be indicative of a pattern of the family communicating for the client.
3. A lack of eye contact with verbal communication may be cultural, not a language barrier.
4. The client that moves away from the nurse when approached may be modest, prefer minimal touch, or require greater personal space.
5. When a client understands minimal English or none at all and is embarrassed or does not know how to communicate that they cannot speak English, they often just nod and agree while the nurse is speaking