一名 55 歲高血壓病史病患主訴突發嚴重頭痛與視力模糊。血壓 210/130 mmHg。下列何者為優先護理措施？
A 55-year-old client with a history of hypertension reports a sudden onset of severe headache and blurred vision. Blood pressure is 210/130 mmHg. What is the priority nursing intervention?
- APrepare for rapid sequence intubation準備快速順序插管
- BPlace the client in a high-Fowler's position將病人置於高福勒氏臥位
- CPerform a comprehensive neurological assessment✓ 正解執行全面的神經學評估
- DAdminister oral antihypertensive medication給予口服抗高血壓藥物
病人血壓 210/130 且伴隨頭痛與視力模糊，屬於高血壓急症（hypertensive emergency）並可能伴隨末端器官（end-organ）損害——在此特別提示腦血管事件（如顱內出血、後循環缺血或高血壓性腦病）的可能。在現有選項中，C「進行完整神經學評估」是合理且優先的護理動作：需評估意識狀態、瞳孔反應、肢體力與感覺，作為後續處置（IV 降壓藥、影像學）的依據。其他選項：D 口服降壓藥對急症太慢；B 高坐臥位屬支持性處置，無法處理根本問題；C 除非氣道喪失保護，否則不應急著插管。注意實際急救中也會同步啟動 IV 降壓藥（如 nicardipine、labetalol），但此選項未列出。
A blood pressure of 210/130 mmHg accompanied by headache and blurred vision indicates a hypertensive emergency with potential end-organ damage; in this scenario, a cerebrovascular event (such as intracranial hemorrhage, posterior circulation ischemia, or hypertensive encephalopathy) should be specifically considered. Among the available choices, option C — performing a comprehensive neurological assessment — is the appropriate and priority nursing action: evaluating level of consciousness, pupillary response, and motor and sensory function provides the foundation for subsequent management (IV antihypertensives, imaging). Of the other options: A, oral antihypertensives are too slow for an emergency; B, high-Fowler's positioning is supportive but does not address the underlying problem; C, intubation is not indicated unless airway protection is lost. In actual practice IV antihypertensives (such as nicardipine or labetalol) would also be initiated concurrently, but this option is not listed.
美國有嚴格的高血壓緊急與急症處理指引；台灣臨床常規使用舌下錠或靜脈注射降壓藥物，護理師需密切監控給藥後反應。