A nurse is performing an admission assessment on an older patient who presented with a high fever and cough, reduced oral intake for 3 days, and lower extremity weakness. The patient has sunken eyes, and the patient’s skin turgor over the sternum is poor. The nurse suspects that the patient is dehydrated. Which of the following are indicators of dehydration in this patient? (Select all that apply.)

Choice A reason: Use of a commode close by to where the client spends most of his time can reduce the distance and time required for the client to reach the toilet, and thus prevent accidents and embarrassment. It can also promote the client's independence and dignity.

Choice B reason: Development of a toileting schedule can help the client to establish a routine and habit of voiding at regular intervals, and thus prevent the bladder from becoming too full or overactive. It can also reduce the risk of urinary tract infections and skin breakdown.

Choice C reason: Use of an external catheter is not recommended for older adults with dementia, as it can cause irritation, infection, and obstruction of the urinary tract. It can also increase the client's confusion and agitation, and interfere with his mobility and comfort.

Choice D reason: Bladder diary to be completed by the client's wife is not a direct intervention to manage the incontinence, but rather a tool to assess the pattern and severity of the problem. It can help the nurse to identify the possible causes and triggers of the incontinence, and to evaluate the effectiveness of the interventions. However, it may not be feasible or reliable for the client's wife to complete the diary, as she may have other responsibilities or difficulties in observing and recording the client's urinary habits.

Choice A reason: Having stable vital signs does not necessarily mean that the client is not experiencing pain. Vital signs can be affected by various factors, such as medications, stress, or emotions, and may not reflect the true level of pain.

Choice B reason: Holding abdomen tightly is a possible sign of pain, especially if the client had abdominal surgery or has a condition that affects the digestive system. The client may be guarding the painful area or trying to relieve the discomfort.

Choice C reason: Not verbalizing is not a reliable indicator of pain, especially for clients with dementia who may have difficulty communicating or expressing their feelings. The nurse should look for other cues, such as facial expressions, body language, or behavioral changes, to assess the client's pain.

Choice D reason: Moving during sleep is not a specific sign of pain, and may be normal for some clients. However, if the client is restless, agitated, or moaning during sleep, it may indicate that the client is in pain and needs intervention.