The emergency department nurse admits a patient who presents with penetrating abdominal trauma. On exam, the patient is agitated, disoriented, and cannot remember how they got to the hospital. What is the priority action by the nurse?

A. Stabilize the penetrating object: Stabilizing the object is important to prevent further internal injury and bleeding. However, immediate assessment of the patient’s vital signs takes priority to determine hemodynamic stability and guide emergent interventions. Life-threatening conditions must be identified before procedural measures. B. Contact the health care provider: Notifying the provider is necessary for treatment planning, but it should occur after the nurse has rapidly assessed the patient’s condition. Vital signs provide critical information to communicate effectively about the patient’s urgency and status. C. Obtain the client’s vital signs: Assessing vital signs is the priority because the patient’s agitation, disorientation, and altered memory may indicate hypovolemic shock, internal hemorrhage, or head injury. Early detection of hypotension, tachycardia, or hypoxia is essential to initiate lifesaving interventions immediately. D. Have the unlicensed assistive personnel place wrist restraints: Restraints may be considered only if the patient poses a danger to self or others, and only after safety measures and assessments are completed. Applying restraints prematurely does not address potentially life-threatening physiologic instability.