一位 55 歲高血壓病史個案自述嚴重頭痛、視力模糊及混亂，血壓 210/130 mmHg。護理師優先採取的行動為何？
A 55-year-old client with a history of hypertension reports severe headache, blurred vision, and confusion. Blood pressure is 210/130 mmHg. Which nursing action is the priority?
- AAdminister an oral antihypertensive medication給予口服抗高血壓藥物
- BPrepare for immediate administration of IV antihypertensives✓ 正解準備立即靜脈給予抗高血壓藥物
- CObtain a baseline neurological assessment取得基線神經系統評估
- DPlace the client in a semi-Fowler's position將客戶置於半坐臥位
此為高血壓急症（Hypertensive Emergency），目標是將血壓在數小時內緩慢下降以防止器官受損。靜脈注射降壓藥物作用迅速且可精確滴定，是臨床標準處置。口服藥物吸收慢，無法及時控制器官風險。採半坐臥位有助於減輕腦壓，但非最直接的藥物治療行動。
This is a hypertensive emergency, and the goal is to lower the blood pressure gradually over several hours to prevent end-organ damage. Intravenous antihypertensives act rapidly and can be precisely titrated, making them the standard of care. Oral medications are absorbed too slowly to control the risk to organs in a timely manner. Placing the client in a semi-Fowler's position can help reduce intracranial pressure, but it is not the most direct pharmacologic action.
美國醫院急診常有標準 Protocol 處理高血壓急症；台灣臨床通常由醫師評估後開立醫囑，護理師監控滴速。