A nurse is assessing a client who is nonverbal for acute pain. Which of the following findings is a manifestation of pain?

A) Exposed bone: Exposed bone is a manifestation of a stage 4 pressure ulcer, where full-thickness skin loss occurs, exposing muscle, tendon, or bone. In stage 3 pressure ulcers, the skin loss extends into the subcutaneous tissue, but it does not reach the level of exposing underlying structures like bone.

B) Blood-filled blisters: Blood-filled blisters can occur in various stages of pressure ulcers, but they are not specific to stage 3. They may be present in stage 1 or stage 2 pressure ulcers as well.

C) Necrotic subcutaneous tissue: This is the correct manifestation of a stage 3 pressure ulcer. Stage 3 pressure ulcers involve full-thickness skin loss with visible necrosis or damage to the subcutaneous tissue. The ulcer may appear as a deep crater with or without undermining of adjacent tissue.

D) Partial-thickness skin loss: Partial-thickness skin loss is characteristic of stage 2 pressure ulcers, where the ulcer extends through the epidermis and into the dermis but does not involve deeper tissue layers like the subcutaneous tissue.

A) "Would you like to talk about your concerns?": This response acknowledges the client's feelings and offers support and an opportunity to discuss their concerns further. It respects the client's autonomy and allows them to express their thoughts and feelings about the situation.
B) "Why don't you want to tell your partner your diagnosis?": This response may come across as confrontational and judgmental, potentially making the client feel defensive. It does not facilitate open communication or address the client's concerns in a supportive manner.
C) "If I were you, I would tell my partner.": This response imposes the nurse's values and beliefs on the client, which may not be helpful or appropriate. It undermines the client's autonomy and decision-making process.
D) "Most people find it helpful to talk to their partner.": While this statement may be true for some individuals, it assumes that the client's situation is the same as others and does not take into account the client's unique circumstances and preferences. It does not encourage open dialogue or address the client's concerns directly.