A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.).

Choice A rationale:

This situation represents an example of assault. Assault is the threat of bodily harm or unwanted physical contact, which creates an apprehension of fear in the victim. In this case, the laboratory technician's actions of restraining the client's arm against their will for blood drawing without consent is a form of assault as it involves an intentional act causing fear of harm.

Choice B rationale:

While telling a client that the nurse "does not know anything" is unprofessional and disrespectful, it doesn't constitute assault. This scenario is more related to issues of communication and respect rather than a direct threat of physical harm.

Choice C rationale:

Restraining a client at bedtime to prevent wandering is not assault. This scenario might involve ethical considerations and the appropriate use of restraints, but it doesn't meet the legal definition of assault, which involves a threat of physical harm.

Choice D rationale:

Threatening to tie down a client if they try to get up from the chair is an example of assault. This action creates an apprehension of fear in the client by implying a physically harmful act. It's a direct threat that falls under the category of assault.

The correct answer is choice B. Necrotic subcutaneous tissue.

Choice A rationale:

Partial-thickness skin loss (Choice A) is characteristic of a stage II pressure ulcer, not a stage III ulcer. A stage II pressure ulcer involves the loss of the epidermis and possibly the dermis, resulting in a shallow open ulcer with a red-pink wound bed.

Choice B rationale:

Necrotic subcutaneous tissue is a manifestation of a stage III pressure ulcer. A stage III ulcer involves full-thickness skin loss where subcutaneous fat may be visible, but exposed bone or muscle is not yet present. Necrotic tissue in the wound bed indicates a more advanced level of tissue damage and the need for appropriate wound care to promote healing.

Choice C rationale:

Blood-filled blisters (Choice C) are not specific to pressure ulcers and are more commonly associated with friction or shear forces. These blisters are not indicative of a stage III pressure ulcer, which involves visible full-thickness tissue loss.

Choice D rationale:

Exposed bone (Choice D) is a characteristic of a stage IV pressure ulcer, not a stage III ulcer. A stage IV ulcer involves extensive tissue loss with exposure of muscle, tendon, or bone. This represents a severe level of tissue damage and requires intensive wound care and management.