The nurse in the emergency department is caring for assigned clients . The nurse should first assess the client who has a
1 . blood pressure of 160/92 mm Hg and reports the worst headache of the client's life
2 . displaced fracture of the tibia and rates pain as 10 on a scale f 0-10
3 . cough productive of green sputum and a respiratory rate of 22 / min
4 . temperature of 101.9 F (38.8 C) and is confused