The nurse is reviewing the record for a client seen in the health care clinic and notes that the health care provider has documented a diagnosis of amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder should the nurse expect to see documented in the record?

A. Mild clumsiness, such as difficulty with fine motor tasks (e.g., buttoning a shirt or writing), is often an early sign of ALS, reflecting initial weakness and muscle dysfunction. B. ALS typically does not affect mental status in the early stages; cognitive functions remain intact in most patients. C. Muscle wasting occurs as the disease progresses, but it is not usually the first sign. D. A diminished gag reflex may develop later in the disease as bulbar involvement increases, but it is not an initial manifestation.