A client who attempted suicide by hanging is brought to the ...

[mrsjacobs44]

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.

Question 2

The nurse is caring for a child who was brought to the clinic complaining of severe abdominal pain and is suspected of having acute appendicitis. The child is lying on the examining table, with the knees pulled up toward the chest.
 
  The nurse assists the physician with further assessment of the progression of the child's pain, knowing that the physician will palpate the abdomen: 1. Midway between the liver and the gallbladder
  2. Midway between the left iliac crest and the umbilicus
  3. Midway between the left inguinal area and the acetabulum
  4. Midway between the right anterior superior iliac crest and the umbilicus

[Pariscourtney]

Answer to Question 1

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.

Answer to Question 2

4

Rationale: McBurney's point is usually the location of greatest pain in the child with appendici-tis. McBurney's point is midway between the right anterior superior iliac crest and the umbilicus. Midway between the liver and the gallbladder, midway between the left iliac crest and the umbilicus, and midway between the left inguinal area and the acetabulum will not appropri-ately assess the progression of pain in the child with appendicitis.