The nurse is assessing the patient by grasping a fold of skin on his forearm.She notices that the skin remains suspended for a longer than normal period.What could this indicate?
A)Stage 1 pressure ulcer
B)Increased blood flow to the area
C)Localized vasodilation
D)Dehydration

Question

Quizplus · Accepted Answer

With reduced turgor,the skin remains suspended or "tented" for a few seconds before slowly returning to place.This indicates decreased elasticity and possible dehydration.A stage 1 pressure ulcer may cause warmth and erythema (redness)of an area.Skin temperature reflects an increase or decrease in blood flow.Normal reactive hyperemia (redness)is a visible effect of localized vasodilation,the body's normal response to lack of blood flow to underlying tissue.

The Nurse Is Assessing the Patient by Grasping a Fold