The nurse is completing a physical examination for a client who ...

[arivle123]

The nurse is completing a physical examination for a client who is anemic. In assessing the cli-ent's eyes, a sign assessed by the nurse that is consistent with the diagnosis is:
 
  1. Xanthelasma
  2. Petechiae
  3. Corneal arcus
  4. Pale conjunctiva

Question 2

The nurse is reviewing the results of the client's diagnostic testing for pulmonary function. Of the following results, the finding that falls within expected or normal limits is:
 
  1. SpO2 88
  2. pH 7.52
  3. PaCO2 55 mm Hg
  4. Decreased peak expiratory flow rate (PEFR) from prior assessment

[Dinolord]

Answer to Question 1

ANS: 4
Pale conjunctiva is an assessment finding consistent with the diagnosis of anemia. Xanthelasma is caused by hyperlipidemia. Petechiae appear on the skin in clients with platelet deficiency (thrombocytopenia). Petechiae on the conjunctivae is consistent with a fat embolus or bacterial endocarditis. Corneal arcus is caused by hyperlipidemia in young to middle-age adults. It is a normal finding in older adults with arcus senilis.

Answer to Question 2

ANS: 3
The normal SpO2 is 98 to 100; the client's measurement is low at 88. The normal pH is 7.35 to 7.45; the client's pH is high at 7.52. The normal PaCO2 is 35 to 45 mm Hg; the client's PaCO2 is elevated at 55 mm Hg. The normal PEFR should increase or remain the same when compared to the prior assessment. A decreased PEFR would indicate airway obstruction. Predicted values are based on age, sex, and height.