A client who attempted suicide by hanging is brought to the emergency department by emergency medical services. The immediate nursing action is which of the following?
1. Take the client's vital signs.
2. Call the mental health crisis team and notify them that a client who attempted su-icide is being admitted to the hospital.
3. Perform a focused assessment, paying particular attention to the client's neuro-logical status.
4. Assess the client's respiratory status and for the presence of neck injuries.
4
Rationale: The immediate nursing action for a client who attempted suicide is to assess physio-logical status. Airway is always the priority. Therefore, assessing the client's respiratory status and for the presence of neck injuries is the immediate action that the nurse takes. Although "take the client's vital signs," "call the mental health crisis team and notify them that a client who at-tempted suicide is being admitted to the hospital," and "perform a focused assessment, paying particular attention to the client's neurological status" identify appropriate nursing actions, they are not the priority.
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