The nurse finds that a patient’s skin tents when assessing skin turgor. How would the nurse interpret this finding?

Choice A reason: Malnutrition may cause skin changes like dryness or thinning but does not typically cause tenting. Tenting reflects loss of skin elasticity due to fluid deficit, not primarily nutritional deficiency, making this an incorrect interpretation of the finding.

Choice B reason: Overhydration causes skin edema, leading to pitting or swelling, not tenting. Tenting occurs when skin lacks moisture and elasticity, which is the opposite of fluid excess, making this an incorrect interpretation of the observed skin turgor.

Choice C reason: Severe edema results in swollen, pitting skin due to fluid retention, not tenting. Tenting indicates a lack of interstitial fluid, as seen in dehydration, making this an incorrect interpretation of the skin turgor finding.

Choice D reason: Skin tenting, where skin slowly returns to its normal position after pinching, indicates severe dehydration. This occurs due to reduced interstitial fluid and loss of skin elasticity, commonly seen in significant fluid loss, making this the correct interpretation.

Choice A reason: Diet and weight provide partial insight into health but are incomplete. Diet is subjective and hard to quantify, and weight alone does not account for growth patterns or proportionality, making it less comprehensive than height and weight.

Choice B reason: Temperature and pulse reflect acute physiological status, not overall health. These vital signs can be normal despite chronic conditions or growth issues, making them inadequate as a primary index for a child’s general health status.

Choice C reason: Height and strength are not typically paired as a standard health index. Strength is subjective and difficult to measure consistently in children, while height alone misses weight-related nutritional status, making this less effective.

Choice D reason: Height and weight are key indicators of a child’s general health, reflecting growth, nutritional status, and development. These measurements, plotted on growth charts, allow comparison to age-specific norms, making them the best index for assessing overall health.