Which assessment is a nonverbal sign of pain? (Select all that apply.)

Choice A reason: This is not the priority assessment, but it is an important assessment for a client with a femur fracture. Pain is the unpleasant sensation that results from tissue damage or inflammation. Pain can affect the client's physical and psychological wellbeing and interfere with their recovery. The nurse should assess the client's pain level, location, quality, and duration using a valid and reliable pain scale. The nurse should also provide pain relief measures, such as medication, ice, elevation, or distraction, as ordered and as needed.

Choice B reason: This is not the priority assessment, but it is a relevant assessment for a client with a femur fracture. Medication history is the record of the drugs that the client is currently taking or has taken in the past, including prescription, overthecounter, herbal, or recreational drugs. Medication history can help the nurse identify any potential drug interactions, allergies, or contraindications that may affect the client's treatment and recovery. The nurse should ask the client about their medication history and document it accurately and completely.

Choice C reason: This is not the priority assessment, but it is a helpful assessment for a client with a femur fracture. Socioeconomic status is the measure of the client's income, education, occupation, and social class. Socioeconomic status can influence the client's access to health care, ability to afford treatment, compliance with therapy, and support system. The nurse should assess the client's socioeconomic status and provide appropriate referrals, resources, or assistance as needed.

Choice D reason: This is the priority assessment for a client with a femur fracture. Pedal pulses are the pulses that can be felt in the feet, such as the dorsalis pedis or the posterior tibial pulse. Pedal pulses can indicate the blood flow and perfusion to the lower extremities, which can be compromised by a femur fracture. A femur fracture can cause bleeding, swelling, or pressure that can reduce or obstruct the blood supply to the feet, leading to ischemia, necrosis, or gangrene. The nurse should assess the client's pedal pulses regularly and report any changes, such as absent, weak, or thready pulses. The nurse should also monitor the client's skin color, temperature, sensation, and movement in the feet.

Choice A reason: Blanching is not the term for black and necrotic tissue. Blanching is the temporary whitening of the skin when pressure is applied. It indicates that the blood flow is intact and the tissue is healthy.

Choice B reason: Cellulitis is not the term for black and necrotic tissue. Cellulitis is a bacterial infection of the skin and subcutaneous tissue. It causes redness, swelling, warmth, and pain in the affected area.

Choice C reason: Tunneling is not the term for black and necrotic tissue. Tunneling is a narrow channel or pathway that extends from the wound into the surrounding tissue. It indicates a deeper and more complex wound.

Choice D reason: Eschar is the term for black and necrotic tissue. Eschar is a thick, dry, and hard crust that forms over a wound. It indicates a severe tissue damage and impaired healing.