When assessing skin turgor in a client, the nurse observes that the skin remains elevated for about 2 seconds. How would the nurse document the skin tenting?
A) +1
B) +2
C) +3
D) +4
B
Feedback:
The nurse should document the skin tenting as +2 because the tent remained for about 2 seconds. A scale of +1 to +4 is commonly used to describe tenting. If the skin does not return to its normal position in 1, 3, or 4 seconds, the observation is documented as +1, +3, or +4 skin tenting, respectively.
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