一名 55 歲高血壓病史病患因血壓 190/110 mmHg 及劇烈頭痛入院。護理師首要採取哪項行動？
A 55-year-old client with a history of hypertension is admitted with a blood pressure of 190/110 mmHg and a severe headache. Which nursing action is the priority?
- APlace the client in a semi-Fowler's position將病人置於半坐臥位
- BAdminister the prescribed PRN antihypertensive medication給予處方之按需降壓藥物
- CAssess the client for neurological changes✓ 正解評估病人是否有神經學變化
- DObtain a complete set of vital signs測量完整組生命徵象
血壓 190/110 mmHg 伴隨劇烈頭痛，高度懷疑為高血壓急症（Hypertensive emergency）。此時最擔心的併發症是標的器官損傷（Target organ damage），特別是腦部。護理師必須優先進行神經學評估（Neurological assessment），以判斷是否有腦出血、中風或高血壓腦病變的徵象，這是決定後續醫療介入急迫性的關鍵。
A blood pressure of 190/110 mmHg accompanied by severe headache strongly suggests a hypertensive emergency. The most worrisome complication at this point is target organ damage, especially of the brain. The nurse must prioritize a neurological assessment to determine whether there are signs of intracerebral hemorrhage, stroke, or hypertensive encephalopathy, which is key to deciding the urgency of subsequent medical intervention.