一位 55 歲高血壓病史病患主訴劇烈頭痛、視力模糊及噁心，血壓 220/130 mmHg。護理師應優先採取何種行動？
A 55-year-old client with a history of hypertension reports a sudden, severe headache, blurred vision, and nausea. Blood pressure is 220/130 mmHg. Which action is the priority for the nurse?
- AAdminister an oral antihypertensive medication給予口服抗高血壓藥物
- BPerform a neurological assessment including pupils and level of consciousness✓ 正解進行包含瞳孔與意識水準的神經學評估
- CPrepare for rapid IV administration of antihypertensive agents準備快速靜脈注射抗高血壓劑
- DElevate the head of the bed to 45 degrees將床頭抬高 45 度
此為高血壓危象（Hypertensive Crisis），病人已有末梢器官損傷跡象（神經系統症狀）。護理師首要任務是評估神經學狀態以建立基準線，判斷是否發生高血壓性腦病變或中風。降壓藥需由醫師依據嚴謹的速度評估後給予，過快降壓可能導致腦部灌流不足。
This is a hypertensive crisis, and the client already shows signs of end-organ damage (neurologic symptoms). The nurse's first task is to assess the neurologic status to establish a baseline and to determine whether hypertensive encephalopathy or stroke has occurred. Antihypertensive medications must be given by the physician after careful evaluation of the rate of administration, since rapid blood pressure reduction may cause cerebral hypoperfusion.
美國醫護系統更強調高血壓危象下的精確神經評估，台灣臨床較常由醫師直接決定降壓藥物並由護理師快速監測。