After completing an integument physical examination, the nurse is documenting information concerning observed lesions. What characteristics will the nurse include in this documentation? (Select all that apply.)

A) Dehydration:

When the skin remains tented and returns to its normal position slowly after being pinched, it indicates decreased skin turgor, which is a clinical sign of dehydration. Dehydration can occur due to fluid loss from sweating during vigorous physical activity like a beach tournament.

B) Hypervolemia:

Hypervolemia refers to excess fluid volume in the body, which would typically manifest with signs such as peripheral edema or jugular vein distention rather than decreased skin turgor.

C) Properly Hydrated:

Properly hydrated individuals would have normal skin turgor, where the skin returns promptly to its normal position after being pinched.

D) Infection:

Skin tenting is not a specific sign of infection. Infection would typically present with localized signs such as redness, warmth, swelling, and possibly systemic signs like fever.

A. Measure nerve function in the fingers:

Measuring nerve function typically involves different assessments, such as checking sensation or performing nerve conduction studies. The action in the image is not indicative of a nerve function test.

B. Monitor oxygen status:

Monitoring oxygen status is usually done with a pulse oximeter, which is placed on the finger but does not involve the manual action shown in the image. The image depicts a manual technique, not a pulse oximetry procedure.

C. Determine capillary refill:

The action shown in the image is a technique used to determine capillary refill time. The nurse presses on the nail bed until it blanches and then releases it to see how quickly the color returns. This assesses peripheral perfusion and can indicate circulatory status.

D. Assess finger range of motion:

Assessing finger range of motion involves moving the fingers through their full range of motion, such as flexing, extending, abducting, and adducting them. The action in the image does not reflect these movements and is more indicative of assessing capillary refill.