When caring for an older adult client who does not speak English, which assessment tool is the most appropriate for the nurse to use to assess this client's pain?
1. The FACES rating scale
2. An interpreter
3. The client's affect
4. The client's vital signs
1
Rationale 1: The FACES rating scale will help the nurse to respond to the client's pain appropriately and quickly.
Rationale 2: An interpreter might not always be readily available.
Rationale 3: Affect might not be accurate indicators of the client's discomfort.
Rationale 4: Vital signs might not be accurate indicators of the client's discomfort.
Global Rationale: An interpreter might not always be readily available, so the FACES rating scale can be used because it is not necessary to use language. If an interpreter is available the nurse can ask the interpreter to discuss the pain in more detail, but the FACES rating scale will help the nurse to respond to the client's pain appropriately and quickly without waiting for an interpreter. Affect and vital signs might not be accurate indicators of the client's discomfort.
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