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) Assess the patient's breathing independent of vocalization.
C) Note whether the patient is calling out, groaning, or crying.
D) Have the patient rate pain on a 1-to-10 scale.
E) Observe the patient's body language for pacing and agitation.
Correct Answer:
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