The nurse is assessing the client's eyes. For each finding, click to specify whether the finding is normal or abnormal

A. Jaundice is a yellow discoloration of the skin and sclera caused by elevated bilirubin levels. It is commonly associated with liver disease, bile duct obstruction, or excessive red blood cell destruction (hemolysis). Although certain types of hemolytic anemia may lead to jaundice, jaundice is not a typical or expected finding in most forms of anemia. Therefore, this is not the best answer.

B. Cyanosis is a bluish discoloration of the skin due to decreased oxygen saturation in the blood. It is typically associated with respiratory disorders, cardiac conditions, or severe hypoxemia. In anemia, oxygen saturation may remain normal, but there is a reduced number of red blood cells or hemoglobin available to carry oxygen. Therefore, cyanosis is not a common finding in uncomplicated anemia.

C. Flushed, warm skin is commonly seen with fever, infection, or vasodilation. It is not characteristic of anemia. Anemic clients typically have decreased hemoglobin levels, leading to reduced oxygen delivery and a pale appearance rather than flushing.

D. Generalized pallor is a classic and expected finding in anemia. Anemia results in decreased hemoglobin and reduced red blood cell count, which leads to less oxygenated blood circulating near the skin surface. This causes the skin, mucous membranes, nail beds, and conjunctiva to appear pale. Pallor may be especially noticeable in the face, palms, and inner eyelids. This is the most consistent and expected skin finding in a client with anemia.

A. Cerumen (earwax) accumulation is something the nurse can directly observe during inspection of the external auditory canal. Because it is visible and measurable, it is considered an objective finding.

B. The condition of the skin around the ear can be directly observed. Dryness and flakiness are visible physical characteristics, making this an objective assessment finding.

C. Pain is a subjective symptom, meaning it is reported by the client and cannot be directly measured or observed by the nurse. Even if the nurse elicits pain by palpation, the sensation itself is based on the client’s report, making it subjective.

D. Visualization of the cone of light during otoscopic examination is a directly observable physical sign of the tympanic membrane’s condition. This makes it an objective finding.

E. Tenderness, like pain, is based on the client’s report during palpation. Although the nurse performs the assessment, the determination of tenderness depends on the client’s perception, making it subjective.