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The nurse is admitting a 77-year-old male patient with dementia to the ER for frequent ground level falls. (GLF) The vital signs are as follows: T37; BP 141/84; HR 93; RR26; O2 94%RA. In assessing this patient for pain, the nurse know that which of these are appropriate to assess for this patient? Select all that apply.- Note any behavior such as calling out, groaning, or crying.- Note if the patient is pacing or agitated.- Asking the patient, "Do you have pain?"- Have the patient describe the quality of their pain.- Assess the patient's breathing patterns.
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