During an Admission Assessment of a Patient with Dementia, the Nurse

During an admission assessment of a patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? (Select all that apply.)

A) Ask the patient, "Do you have pain?"
B) Have the patient rate pain on a 1-to-10 scale.
C) Assess the patient's breathing independent of vocalization.
D) Note whether the patient is calling out, groaning, or crying.
E) Observe the patient's body language for pacing and agitation.