一名 55 歲高血壓病史病患主訴突然發生嚴重頭痛。護理師應優先進行哪項評估？
A 55-year-old client with a history of hypertension reports a sudden, severe headache. Which of the following is the priority assessment for the nurse?
- ABlood pressure reading✓ 正解血壓讀數
- BLevel of consciousness意識水準
- CBlood glucose level血糖值
- DPupillary response瞳孔反應
高血壓病史伴隨突發性劇烈頭痛，優先考慮高血壓急症（Hypertensive crisis）或腦血管意外。測量血壓是診斷高血壓急症的首要依據，若血壓極高，需立即介入以防腦部或心臟損傷。其他神經學評估雖重要，但在排除高血壓因素前，血壓數據對立即治療決策最具決定性。
A history of hypertension combined with the sudden onset of severe headache should raise concern for hypertensive crisis or cerebrovascular accident. Measuring blood pressure is the primary basis for diagnosing a hypertensive emergency; if the blood pressure is extremely elevated, immediate intervention is required to prevent cerebral or cardiac injury. Although other neurological assessments are important, the blood pressure reading is the most decisive piece of information for immediate treatment decisions before hypertensive causes are ruled out.
美國護理師常需依據血壓數據觸發自動處置標準（Protocol）；台灣通常量測後需聯繫值班醫師確認處置。