The visiting nurse observes that the older male client is confined by his daughter to his room. When the nurse suggests that he walk into the den and join everyone, he says "I'm in everyone's way, my daughter needs me to stay here." The most important action for the nurse is to:

Correct Answer: A

Rationale: The correct answer is A because suggesting appropriate resources like respite care and a senior citizens' center shows the nurse's understanding of the client's needs for social interaction and support. This approach addresses the client's isolation and the daughter's need for assistance in caring for her father. Choice B is incorrect because simply telling the daughter to allow her father to participate does not address the underlying issues of the client feeling in the way and the daughter's need for support. Choice C is incorrect as it ignores the client's need for social interaction and the daughter's need for assistance, prioritizing peace over the client's well-being. Choice D is incorrect as offering to stay with the client while he is isolated does not address the broader issue of the client's need for social engagement and the daughter's need for support.

Correct Answer: B

Rationale: The correct answer is B because antibiotics are not standard therapy for congestive heart failure in the elderly. The rationale is that antibiotics are used to treat bacterial infections, not heart failure. A: ACE inhibitors are standard therapy as they help dilate blood vessels and reduce the workload on the heart. C: Diuretics help reduce fluid buildup in the body, which is beneficial for managing CHF symptoms. D: Beta blockers are used to reduce the heart's workload and help manage the stress response, making them standard therapy for CHF.

Correct Answer: C

Rationale: The correct answer is C: Being adequately nourished. Malnutrition weakens the immune system, making individuals more susceptible to infections like tuberculosis. Diabetes (A), living in crowded institutions (B), and immunosuppression (D) all lower immunity, increasing the risk of developing TB. In summary, adequate nutrition is not a risk factor for TB in the elderly, while diabetes, institutional living, and immunosuppression are.

Correct Answer: D

Rationale: The correct answer is D, dramatic loss of melanin. Melanin is a pigment responsible for skin color and does not play a role in the development of pressure ulcers. Shearing, decreased body weight, and malnutrition (decreased serum albumin) are all known risk factors for pressure ulcers in the elderly. Shearing can lead to tissue damage, decreased body weight can indicate poor nutrition and muscle wasting, and malnutrition can impair wound healing and skin integrity. Therefore, D is the correct answer as it does not contribute to the likelihood of an elderly person developing a pressure ulcer.

Correct Answer: A

Rationale: The correct answer is A: Monitor the client's blood glucose level. Tremors and confusion in a client with diabetes could indicate hypoglycemia. Monitoring blood glucose levels will confirm if the client's symptoms are due to low blood sugar. Providing a full meal (B) may worsen the situation by delaying the increase in blood sugar. Asking the client to rest (C) does not address the underlying cause. Administering insulin immediately (D) without knowing the current blood glucose level can further lower blood sugar levels. Hence, monitoring the blood glucose level is the most appropriate initial action.