一名 45 歲高血壓病史病患主訴突發嚴重頭痛與視力模糊。測得血壓為 210/130 mmHg。護理師應優先採取何種行動？
A 45-year-old client with a history of hypertension reports a sudden onset of severe headache and blurred vision. Blood pressure is 210/130 mmHg. Which nursing action is the priority?
- AAdminister ordered oral antihypertensive medication給予處方口服降壓藥物
- BPrepare for immediate administration of IV vasodilator✓ 正解準備立即靜脈注射血管擴張劑
- CElevate the head of the bed to 45 degrees將床頭抬高 45 度
- DObtain a complete neurologic assessment進行完整的神經系統評估
此個案呈現高血壓急症（Hypertensive Emergency），器官灌流已受損或有受損風險。首要任務是透過靜脈輸注血管擴張劑來緩慢降低血壓，避免末梢器官缺血，但需嚴密監控。口服藥物起效太慢，床頭抬高僅能短暫緩解但非核心治療，神經評估應在藥物治療開始後併行。
This client presents with hypertensive emergency, with organ perfusion already compromised or at risk. The primary task is to slowly lower the blood pressure with intravenous vasodilators while avoiding end-organ ischemia, but with close monitoring required. Oral medications act too slowly, elevating the head of bed only provides temporary relief and is not a core treatment, and neurological assessment should proceed in parallel after pharmacologic therapy has begun.
美國護理師在 ICU/ER 常需負責滴定血管擴張劑；台灣通常由醫師下醫囑並密切監控，護理師依醫囑調整劑量。