一位 55 歲高血壓病史病人主訴突發性劇烈頭痛、頸部僵硬及畏光。護理師應優先採取何種行動？
A 55-year-old client with a history of hypertension reports a sudden, severe headache, neck stiffness, and photophobia. Which action is the priority?
- APlace the client in a quiet, darkened room將病人安置於安靜、昏暗的房間
- BPrepare for a lumbar puncture準備進行腰椎穿刺
- CPerform a neurological assessment using the Glasgow Coma Scale✓ 正解使用格拉斯哥昏迷量表進行神經學評估
- DAdminister a prescribed analgesic給予處方止痛藥
此臨床表現強烈暗示蛛網膜下腔出血（SAH）。優先執行 GCS 神經評估以建立基準線（baseline），並隨時監測腦灌注壓或意識水平變化。止痛藥會掩蓋症狀，降至環境刺激僅為緩解，腰椎穿刺則是診斷步驟而非緊急處置，優先評估神經功能穩定性最關鍵。
This clinical presentation strongly suggests subarachnoid hemorrhage (SAH). Priority should be given to performing a GCS neurological assessment to establish a baseline and to monitor cerebral perfusion pressure or changes in level of consciousness on an ongoing basis. Analgesics may mask symptoms; reducing environmental stimuli is only a comfort measure; and lumbar puncture is a diagnostic step rather than an emergency intervention. Priority assessment of neurologic stability is the most critical.
美國護理師常需在 ED 快速篩檢意識改變，台灣臨床通常在急診醫師初步診視後，護理師再進行完整神經學檢查與紀錄。