The spouse brings a client to the emergency department due to erratic behavior and expressions of despair. The emergency department is extremely busy with many clients. When the triage nurse asks if the client feels suicidal now, the client shrugs the shoulders. What INITIAL action should the triage nurse take? 1. Ask the client to make a verbal contract to not harm self 2. Document that the client is not currently suicidal 3. Place the client in an inside hallway with one-on-one observation 4. Return the client to the waiting room with the spouse

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