一名 55 歲有高血壓病史的個案，主訴突發性劇烈頭痛、視力模糊及意識混亂，血壓 210/120 mmHg。護理師應優先採取哪項行動？
A 55-year-old client with a history of hypertension reports a sudden onset of severe headache, blurred vision, and confusion. Blood pressure is 210/120 mmHg. Which nursing action is the priority?
- APrepare for immediate administration of IV antihypertensives✓ 正解準備立即給予靜脈注射抗高血壓藥物
- BAdminister an oral antihypertensive medication給予口服抗高血壓藥物
- CPlace the client in a high-Fowler’s position將個案置於高福勒氏體位
- DPerform a complete neurological assessment進行完整的神經學評估
此個案呈現高血壓急症（Hypertensive Emergency）的特徵，伴隨末梢器官損傷症狀（頭痛、視力模糊、意識改變）。治療的核心目標是在嚴密監控下，於數小時內將平均動脈壓逐漸降低，以防止腦血管意外或進一步的組織灌流傷害。這類危急情況下，靜脈注射（IV）藥物具有起效快、易於調整滴速的優勢，能精確控制血壓下降速度。口服藥物吸收太慢且不可預測，姿勢調整對降低動脈壓無效，神經檢查雖然重要，但在確保血流動力學穩定前，救命性的藥物給予才是首要任務。護理重點在於預防中風及保護重要器官。
This case presents features of a hypertensive emergency, accompanied by signs of end-organ damage (headache, blurred vision, altered consciousness). The core treatment goal is to gradually lower the mean arterial pressure within several hours under close monitoring, in order to prevent cerebrovascular accident or further tissue hypoperfusion injury. Under such critical conditions, intravenous (IV) medications have the advantage of rapid onset and easy titration, allowing precise control over the speed at which blood pressure is lowered. Oral medications are absorbed too slowly and unpredictably; positional changes are ineffective for lowering arterial pressure; and although neurological assessment is important, before hemodynamic stability is ensured, life-saving medication administration is the priority. Nursing focuses on stroke prevention and protection of vital organs.
美國醫院針對高血壓急症通常有嚴格的 ICU 護理 protocol，藥物如 Nicardipine 或 Labetalol 的滴定均由護理師依醫囑執行；台灣則常見醫師親自調整靜脈輸注速率，護理師較少自主滴定，受限於專科護理師職權差異。