一位 45 歲高血壓病史病患主訴劇烈頭痛、視力模糊及噁心，血壓 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, severe headache, blurred vision, and nausea. The client's blood pressure is 210/130 mmHg. Which action is the priority?
- APlace the client in a high-Fowler's position✓ 正解將病人置於高福勒氏體位
- BObtain an ECG取得心電圖
- CAdminister an oral antihypertensive medication給予口服抗高血壓藥物
- DPerform a neurological assessment進行神經學評估
此個案呈現高血壓急症（Hypertensive Crisis），優先處理應是降低顱內壓與減輕心臟負荷。將病患擺位成半坐臥姿（High-Fowler's）有助於改善呼吸及降低腦部血壓。口服藥物作用太慢，需靜脈給藥；神經檢查與心電圖雖重要，但應在擺位與維持呼吸循環穩定後執行。
This client is presenting with a hypertensive crisis; priority management is to lower intracranial pressure and reduce cardiac workload. Placing the client in a high-Fowler's position helps improve respiration and reduce cerebral blood pressure. Oral medications act too slowly; IV administration is needed. Neurologic assessment and ECG are important but should be performed after positioning and stabilizing respiratory and circulatory status.
美國高血壓急症處置多在 ICU 執行，台灣急診處置流程相似，但降壓速度與藥物選擇常受限於區域醫院設備。