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    Hesi rn health assessment proctored exam (retest)

    Which focused assessment technique should the nurse use for a client admitted with possible dehydration?

    Explanation & Rationale

    Rationale: A. Measure the circumference of the calf: Measuring calf circumference is used primarily to assess for deep vein thrombosis (DVT) or edema, not dehydration. It evaluates for swelling but does not give information about the client’s hydration status. B. Grasp skin fold of the posterior forearm: Checking skin turgor by grasping and gently pulling a fold of skin on the posterior forearm is a standard method to assess for dehydration. Poor turgor, where the skin remains tented, suggests fluid volume deficit and supports a diagnosis of dehydration. C. Check hands for parchment-like appearance: A parchment-like appearance of the hands is more related to normal aging changes rather than acute dehydration. It reflects thinning of the skin rather than fluid status, and could lead to misinterpretation if used for hydration assessment. D. Press skin over a bony prominence: Pressing over bony prominences checks for edema or pitting rather than skin elasticity. While edema can coexist with dehydration in complex cases, evaluating turgor is a more direct and sensitive technique for diagnosing dehydration.

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