The nurse is caring for a client who is of a different culture than that of the nurse. When the nurse begins the physical assessment, the client seems apprehensive. What action should the nurse take?

A. Behavior: Behavior is part of the general survey’s behavioral assessment, not physical appearance. It includes mood, affect, and interactions with the environment, focusing on emotional and cognitive functioning rather than physical characteristics.

B. Level of consciousness: Level of consciousness is assessed under mental status or neurological evaluation. While important for overall health assessment, it does not fall under the physical appearance portion of the general survey.

C. Range of motion: Range of motion evaluates musculoskeletal function and joint mobility. This is part of the physical examination, not the initial observational assessment of physical appearance in the general survey.

D. Facial features: Observing facial features is part of physical appearance, as it provides information about symmetry, expressions, and possible congenital or acquired conditions. This helps form an overall impression of the client’s health.

E. Sexual development: Sexual development, such as secondary sex characteristics, is included in the physical appearance portion of the general survey. It offers insight into growth, maturation, and endocrine or developmental issues.

A. Explain the parts of the assessment and ask permission to move forward: Providing a clear explanation of the assessment process and asking for consent demonstrates respect for the client’s cultural values and personal boundaries. This approach helps reduce anxiety, promotes trust, and ensures the client feels in control of their care.

B. Return at a later time to complete the physical assessment and interview: Delaying the assessment may not address the client’s immediate health needs and does not actively engage the client in reducing their apprehension. It may also prolong anxiety without providing reassurance.

C. Get a different nurse to complete the physical assessment and interview: While changing nurses might help in some cases, it does not directly address the client’s apprehension or foster communication and trust. The underlying need is for explanation and consent, not just a change in personnel.

D. Continue with the physical assessment so the client can get treatment: Proceeding without consent disregards the client’s autonomy and may increase anxiety or distrust. It could violate ethical principles and negatively impact the nurse–client relationship.