The nurse teaches an older adult diagnosed with diabetes mellitus and prescribed metoprolol to recognize early clinical indicators of hypoglycemia. Which clinical indicators of hypoglycemia does the nurse include in client teaching as the indicators this man is most likely to detect? (Select all that apply.)

Choice A reason: Raises all four side rails is not the best intervention, as it may not prevent the client from falling and may increase the risk of injury and entrapment. Raising all four side rails may also be considered a form of restraint, which should be avoided unless absolutely necessary.

Choice B reason: Orders a two-person assist with a transfer is not the best intervention, as it may not be appropriate for the client's level of mobility and may reduce the client's independence and self-esteem. The nurse should assess the client's ability to transfer and use the appropriate assistive device and number of staff to ensure safety and comfort.

Choice C reason: Gives the client a dry erase board is the best intervention, as it can facilitate the client's communication and expression of needs and preferences. The client may have difficulty speaking or writing due to the stroke, which can affect the language and motor areas of the brain. A dry erase board can allow the client to use simple words, symbols, or drawings to convey their messages.

Choice D reason: May need to incorporate repetition is not the best intervention, as it is not specific and may not be effective for the client's learning and retention. The nurse should use individualized and evidence-based strategies to teach the client and their family about the stroke, its effects, and the rehabilitation plan. Repetition may be one of the strategies, but not the only one.

Choice E reason: None of the above is not the correct answer, as there is one choice that is the best intervention for the nurse to implement when caring for this client.

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.