The nurse is caring for an aging adult with dementia. Which behavioral clue indicates pain? Select all that apply.

A. Clenched fists: In patients with cognitive impairment, non-verbal cues such as motor tension or guarding are primary indicators of physical distress. Clenched fists often represent an involuntary response to acute or chronic pain when the patient cannot articulate their feelings. This behavior signals an increased sympathetic nervous system activation. B. Shuffling gait: A shuffling gait is a common motor symptom of Parkinson's disease or normal aging and is not a specific indicator of pain. While pain can alter mobility, this particular gait pattern is usually related to neurological changes or balance deficits. It is a chronic physical characteristic rather than a behavioral clue for pain. C. Flat affect: A flat affect is characterized by a lack of emotional expression and is often associated with depression or the progression of dementia itself. Pain more frequently causes an increase in facial activity rather than a decrease. It is not a reliable sign for identifying an acute painful stimulus. D. Moaning: Vocalizations such as moaning, groaning, or whimpering are significant behavioral indicators of pain in non-verbal patients. These sounds often increase during movement or repositioning, suggesting localized or systemic discomfort. The nurse should use these cues to initiate a thorough pain assessment and intervention. E. Grimacing: Facial expressions, including grimacing, furrowed brows, or distorted features, are the most common non-verbal manifestations of pain. These involuntary muscle contractions occur as a direct response to noxious stimuli. They provide clear evidence that the patient is experiencing a level of physiological or psychological distress.