The home care nurse is performing an environmental assessment in the home of an older adult. Which of the following requires immediate nursing action?

Correct Answer: A

Rationale: The correct answer is A: Unsecured scattered rugs. This requires immediate nursing action as it poses a significant fall risk for the older adult. Rugs can cause tripping hazards, leading to potential injuries. The nurse should secure or remove the rugs to ensure the safety of the patient. Summary of other choices: B: Operable smoke detector - While important for safety, it does not require immediate nursing action as it is already in working condition. C: Prefilled medication cassette - This is not an immediate safety concern and can be addressed during routine medication management. D: Unsecured scattered rugs (repeated) - This choice is the same as the correct answer, so it is incorrect.

Correct Answer: A

Rationale: Step 1: Gerontological nursing certification focuses on advanced knowledge and skills for caring for older adults. Step 2: This certification is not a requirement for all nurses in long-term care or limited to rehabilitation centers. Step 3: Nurses with various levels of education, not just a master's degree, can obtain gerontological certification. Therefore, option A is correct as it accurately states that gerontological nursing certification signifies advanced knowledge and skills specific to older adult care. Options B, C, and D are incorrect as they provide inaccurate information about the certification requirements and scope.

Correct Answer: B

Rationale: The correct answer is B because tuberculosis is an infectious bacterial disease that primarily affects the lungs. Clients taking immunosuppressant medications have weakened immune systems, making them more susceptible to developing active tuberculosis. This is due to the fact that the immune system is less able to fight off the bacteria causing tuberculosis. Choices A, C, and D are incorrect because tuberculosis is not spread by persons with positive skin tests and no symptoms, it is caused by bacteria (Mycobacterium tuberculosis) not a virus related to HIV, and it typically causes weight loss and not weight gain in the early stages.

Correct Answer: A

Rationale: The correct answer is A: Diarrhea. Diarrhea is not a risk factor for developing pneumonia in elderly individuals. The rationale for this is that pneumonia is primarily caused by respiratory infections, not gastrointestinal issues like diarrhea. Neurological disease, heart failure, and COPD are all risk factors for pneumonia because they can weaken the immune system or impair lung function, making individuals more susceptible to respiratory infections. These conditions can lead to aspiration, impaired cough reflex, or compromised lung function, increasing the likelihood of developing pneumonia.

Correct Answer: D

Rationale: The correct answer is D because assisting with upper endoscopy is not a standard nursing intervention for CHF. Nursing interventions for CHF focus on managing symptoms, medication adherence, and lifestyle modifications. Choices A, B, and C are correct as they address important aspects of CHF management such as monitoring symptoms, educating on medications, and promoting a low-sodium diet. Helping with an upper endoscopy is unrelated to the management of CHF and falls outside the scope of nursing care for this condition.