一名 45 歲高血壓病史病患主訴突然劇烈頭痛及視力模糊，血壓為 210/130 mmHg。護理師應優先採取什麼行動？
A 45-year-old client with a history of hypertension reports a sudden onset of severe headache and blurred vision. The blood pressure is 210/130 mmHg. Which nursing action is the priority?
- AElevate the head of the bed to 45 degrees✓ 正解將床頭抬高至45度
- BObtain an EKG to check for cardiac ischemia進行心電圖檢查以評估心肌缺血
- CAdminister an oral antihypertensive medication給予口服降壓藥物
- DPrepare the client for immediate admission to the ICU準備將病人立即收治加護病房
此個案呈現高血壓急症（Hypertensive Emergency）。優先將床頭抬高可減少腦部血流量並減輕顱內壓，降低腦水腫風險。藥物治療需經醫師評估後使用靜脈注射劑型；ICU 轉送雖必要，但非現場的第一時間救命措施；EKG 可隨後進行，但非穩定生命徵象的優先項。
This client presents with a hypertensive emergency. Prioritizing head-of-bed elevation reduces cerebral blood flow, alleviates intracranial pressure, and decreases the risk of cerebral edema. Medications should be given intravenously after physician evaluation; ICU transfer, although necessary, is not the on-the-spot lifesaving measure; and ECG can be performed afterward but is not the priority for stabilizing vital signs.
美國醫護對於高血壓急症常有標準化的靜脈降壓藥給藥 protocol；台灣臨床則更嚴謹要求醫師評估後才進行降壓處置。