A nurse in the emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first?

A. While monitoring blood pressure is essential in the overall assessment of a patient, the given blood pressure readings (112/88 mm Hg) are within the normal range. Hence, further evaluation of blood pressure may not be immediately necessary based on the provided information.
B. A temperature of 38.1°C (100.5°F) indicates fever, which can be a sign of infection or inflammatory process. Further evaluation is warranted to determine the cause of the fever and initiate appropriate treatment.
C. The heart rate of 98/min falls within the normal range for adults (60-100 beats per minute). Although heart rate abnormalities can indicate various conditions, the given heart rate alone may not warrant immediate further evaluation without additional concerning symptoms or clinical context.
D. The oxygen saturation of 98% on room air is within the normal range (>95%).

While assessing oxygen saturation is crucial, the provided value does not indicate immediate concern. Further evaluation may be needed if the patient shows signs of respiratory distress or if there is clinical suspicion of hypoxemia.

E. Recent travel to South Africa raises concerns about potential exposure to infectious diseases endemic to that region. Further evaluation is necessary to assess for travel- related illnesses or infections, such as tuberculosis or other tropical diseases.
F. A significant weight loss of 2.26 kg (5 lb) over the last week is concerning and requires further investigation. Unintentional weight loss can be indicative of various underlying medical conditions, including infections, malignancies, or metabolic disorders.
G. The report of "blood-tinged sputum" suggests hemoptysis, which can be a sign of serious underlying conditions such as pulmonary infections, pulmonary embolism, or malignancy. Further evaluation is necessary to determine the cause and initiate appropriate management.
H. The presence of a persistent cough, especially when associated with other symptoms like fatigue, night sweats, and weight loss, raises concerns for underlying respiratory or systemic conditions. Further assessment is needed to identify the cause of the cough and provide appropriate treatment.

A: Alternative communication methods are more applicable to clients with severe speech or cognitive impairments, which are not universally present in multiple sclerosis.
B: Using clock numbers to describe food placement is typically recommended for visually impaired clients, not specifically for those with multiple sclerosis.
C: Touching the client's arm before speaking is a technique used for clients with hearing impairments.
D: Multiple sclerosis can cause fine motor skill impairment and muscle weakness. Providing large-handled utensils can help maintain independence in eating by making it easier to grip and use utensils.