A nurse at an acute care facility is teaching a client about fall risk prevention strategies for use during their stay at the facility.
Which of the following statements by the client indicates an understanding of the teaching?

Choice A rationale: A protective environment is typically indicated for immunocompromised clients, such as those with neutropenia or undergoing chemotherapy, not for uncomplicated anemia. The toddler’s white blood cell count is within the normal range of 5,000 to 10,000/mm³, and no evidence of infection risk or severe immunodeficiency is present. Pallor and low hemoglobin are consistent with iron deficiency anemia, which does not require isolation precautions unless additional hematologic compromise is identified.

Choice B rationale: Blood transfusions are reserved for cases of severe anemia with hemodynamic instability, cardiac compromise, or hemoglobin levels below 7 g/dL. This toddler’s hemoglobin is 8.1 g/dL, which while low, does not meet transfusion threshold in a stable, asymptomatic pediatric patient. Transfusion carries risks like iron overload and alloimmunization, making it inappropriate for mild to moderate anemia. Instead, correction through dietary modification and iron supplementation is preferred for age-related iron-deficiency anemia.

Choice C rationale: Iron supplementation is the standard therapy for iron deficiency anemia, especially in toddlers consuming excessive cow’s milk, which lacks iron and can cause occult intestinal blood loss. Hemoglobin of 8.1 g/dL is below the normal pediatric range of 9.5 to 14 g/dL, confirming anemia. Iron replenishment stimulates erythropoiesis by enabling hemoglobin synthesis. Supplementation corrects deficiency over time and should be paired with dietary education to limit milk to <24 oz/day and include iron-rich foods.

Choice D rationale: Continuing antibiotics is unnecessary unless there is ongoing infection. The toddler has recently completed antibiotic therapy for otitis media, and current symptoms do not suggest infection recurrence. Vital signs are stable and the white blood cell count is within normal limits (5,000–10,000/mm³), indicating no acute bacterial process. Antibiotic overuse may disrupt gut flora, impair iron absorption, and contribute to resistant bacterial strains, which is contraindicated in this clinical scenario.

Choice A rationale

A tympanogram is a diagnostic test that measures the movement of the eardrum in response to changes in air pressure in the ear canal. It is used to assess the function of the middle ear and is not a part of the Weber's test. The Weber's test is a gross screening tool for hearing acuity that uses a vibrating tuning fork to compare bone conduction in both ears, not to evaluate middle ear function.

Choice B rationale

The Weber's test is a simple screening tool to detect unilateral hearing loss. The nurse places a vibrating tuning fork on the midline of the child's head, such as the forehead or the top of the head. The sound is transmitted through the skull bones to the inner ears. The child is asked where the sound is heard best—in the left ear, right ear, or equally in both. This assesses bone conduction.

Choice C rationale

The Weber's test evaluates whether the sound is heard equally in both ears or lateralizes to one ear, indicating a potential conductive or sensorineural hearing loss. It does not measure the duration of sound perception. Measuring the amount of time a client can hear the sound after the tuning fork is placed on the mastoid bone is part of the Rinne test, a different component of hearing assessment, which compares bone and air conduction.

Choice D rationale

Holding a vibrating tuning fork 1 to 2 cm from the ear canal is a procedure used for the Rinne test, not the Weber's test. The Rinne test compares air conduction to bone conduction. The vibrating tuning fork is placed first on the mastoid bone (bone conduction) and then near the ear canal (air conduction). This is used to distinguish between conductive and sensorineural hearing loss. *.