HESI LPN Exit Exam IV Proctored Exam
In performing a focused assessment, the practical nurse (PN) lifts the client's skin as seen in the photo. Which should the PN do next?
Explanation & Rationale
A. Lifting the skin is a common technique used to assess skin turgor, which is the elasticity of the skin.By letting go, the nurse can observe how quickly the skin snaps back into place, indicating good or poor elasticity. B. recording palpated temperature might be done during a focused assessment, but it wouldn't necessarily be the next step after lifting the skin. C. measuring indentation depth might be relevant for assessing edema (swelling), but it's not the primary focus after lifting for turgor. D. observing swelling could be assessed visually without lifting the skin, and while it's important, assessing elasticity comes first in this scenario.
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