The nurse is assessing the skin of a client diagnosed with anemia. Which of the following findings should the nurse expect?

Jaundiced skin tone

Cyanosis of the extremities

Flushed, warm skin

Generalized pallor

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is C

Explanation

A. Dull, throbbing facial pain is most commonly associated with sinusitis, which involves inflammation and pressure within the sinus cavities. While rhinorrhea can accompany sinusitis, pain is not the defining feature of rhinorrhea. The primary symptom of rhinorrhea is nasal discharge, not facial pressure or pain.

B. Difficulty swallowing refers to dysphagia, which involves problems with the throat or esophagus. Although allergies can cause postnasal drip that may irritate the throat, rhinorrhea specifically refers to nasal drainage. This statement focuses on swallowing difficulty rather than nasal discharge.

C. Clear, watery nasal drainage is the classic presentation of rhinorrhea. This description directly matches the definition of the condition. Clients with rhinorrhea often report frequent nose blowing due to continuous drainage.

D. Nosebleeds are known as epistaxis, which involves bleeding from the nasal mucosa. While both rhinorrhea and epistaxis involve the nose, they are distinct conditions with different causes and management.

A. Respirations B. Blood pressure C. Pain D. Heart rate E. Temperature F. Oxygen saturation

Correct Answer is ["B","D"]

Explanation

A. The respiratory rate is not provided in the assessment data. Because no abnormal value is documented, respirations cannot be identified as concerning based on the available information. There is no evidence of tachypnea, bradypnea, or respiratory distress.

B. A blood pressure of 90/58 mmHg is hypotensive. In a 74-year-old client, hypotension is especially concerning because it may indicate decreased organ perfusion. Potential causes include dehydration, blood loss, sepsis, medication effects, or cardiac dysfunction. Older adults have decreased physiologic reserve, so low blood pressure increases the risk for dizziness, falls, syncope, kidney injury, and altered mental status. This finding requires immediate assessment.

C. A pain rating of 1/10 indicates minimal discomfort. This level of pain is mild and not physiologically destabilizing. It does not suggest acute distress or hemodynamic compromise and therefore is not a priority concern.

D. A heart rate of 118 beats per minute is tachycardia. Normal adult heart rate ranges from 60 to 100 beats per minute. Tachycardia in this context is concerning, especially when paired with hypotension. The elevated heart rate may represent a compensatory mechanism in response to low blood pressure in an attempt to maintain cardiac output and organ perfusion. This combination raises concern for early shock, hypovolemia, or other circulatory instability and requires prompt follow-up.

E. A temperature of 98.9°F (37.1°C) is within normal limits. There is no evidence of fever or hypothermia. This value does not indicate infection or systemic instability.

F. An oxygen saturation of 97% on room air is normal and indicates adequate oxygenation. There is no sign of hypoxia or respiratory compromise.

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The nurse is assessing the skin of a client diagnosed with anemia. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is ["B","D"]

Explanation

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