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: Physical status is an important assessment for post-fall prevention, as it can identify the possible causes and consequences of the fall, such as injuries, pain, mobility, balance, strength, vision, hearing, cognition, and medication use. Physical status can also help determine the appropriate interventions and referrals for the older adult, such as physical therapy, occupational therapy, or home health care.

Choice B reason: Financial status is not an essential assessment for post-fall prevention, as it does not directly affect the risk or outcome of the fall. However, financial status may influence the older adult's access to health care, social support, and assistive devices, which may affect their recovery and quality of life. Financial status may also be a source of stress or anxiety for the older adult, which may impair their mental and emotional well-being.

Choice C reason: Occupational history is not an essential assessment for post-fall prevention, as it does not directly affect the risk or outcome of the fall. However, occupational history may provide some information about the older adult's past and current activities, skills, and interests, which may help tailor the interventions and goals for the older adult. Occupational history may also reflect the older adult's sense of identity, purpose, and satisfaction, which may affect their motivation and engagement.

Choice D reason: Environment is an important assessment for post-fall prevention, as it can identify the potential hazards and barriers that may contribute to the fall, such as poor lighting, slippery floors, clutter, loose rugs, stairs, or furniture. Environment can also help determine the appropriate modifications and adaptations that can reduce the risk of future falls, such as installing grab bars, handrails, ramps, or alarms. Environment can also influence the older adult's comfort, safety, and independence at home or in other settings.

Choice E reason: None of the above is not the correct answer, as there are two choices that are essential assessments for post-fall prevention.

Choice A: "Client slept throughout the night" - Good sleep can be an indicator of effective pain management. Pain can disrupt sleep, so if the client is sleeping well, it may suggest that their pain is being effectively managed¹.

Choice B: "Client cooperative during AM care" - If the client is cooperative during care, it may suggest that they are not in significant pain. Uncontrolled pain can make people irritable and uncooperative¹.

Choice C: "Client ate 80% of breakfast, 70% of lunch and 100% of dinner" - Pain can affect appetite. If the client is eating well, it may suggest that their pain is under control¹.

Choice D: "Client winces only when turned and repositioned" - If the client only shows signs of discomfort during movement, it may suggest that their pain is generally well-controlled¹.

Choice E: "Client slept during dressing change" - This is not necessarily an indicator of effective pain management. The client could be sleeping due to fatigue, medication effects, or other reasons unrelated to their pain level¹.