一名45歲高血壓病史病人主訴突發劇烈頭痛、視力模糊及噁心，血壓為210/130 mmHg。護理師優先採取之措施為何？
A 45-year-old client with a history of hypertension reports a sudden, severe headache, blurred vision, and nausea. The blood pressure is 210/130 mmHg. What is the nurse's priority action?
- AElevate the head of the bed to 30-45 degrees✓ 正解將床頭抬高30-45度
- BPerform a neurological assessment including pupil reaction進行包含瞳孔反應的神經學評估
- CAdminister an oral antihypertensive medication給予口服降血壓藥物
- DPlace the client in a supine position讓病人採取仰臥姿勢
此為高血壓急症（Hypertensive Crisis），目標為降低腦內壓並減輕心臟負荷。採取半坐臥姿勢（30-45度）可協助減少靜脈回流，降低腦充血與顱內壓。平躺會加重腦部血流壓力；口服藥物起效太慢，需使用靜脈注射降壓劑。神經檢查固然重要，但物理性擺位屬於優先處理的 ABC 相關處置。
This is a hypertensive crisis, and the goal is to reduce intracranial pressure and the cardiac workload. Placing the patient in a semi-Fowler's position (30-45 degrees) helps reduce venous return and decreases cerebral congestion and intracranial pressure. A flat position increases cerebral blood flow pressure, and oral medications act too slowly, so intravenous antihypertensives must be used. Neurologic assessment is important, but physical positioning is an ABC-related intervention that takes priority.
美國醫院針對高血壓急症有明確的快速反應小組機制；台灣臨床常需先確認醫囑是否已開立降壓藥物，再執行擺位。