一位 55 歲高血壓病史個案，突發劇烈頭痛、頸部僵硬及畏光，護理師懷疑蜘蛛網膜下腔出血。下列何者為優先措施？
A 55-year-old client with a history of hypertension reports a sudden, severe headache, neck stiffness, and photophobia. The nurse suspects a subarachnoid hemorrhage. Which action is the priority?
- AMonitor vital signs every 15 minutes✓ 正解每 15 分鐘監測生命徵象
- BKeep the head of the bed elevated at 30 degrees將床頭抬高 30 度
- CAdminister pain medication給予止痛藥物
- DMaintain a quiet, dark environment維持安靜、昏暗的環境
蜘蛛網膜下腔出血（SAH）為神經急症，再出血風險極高。優先護理動作：D. 每 15 分鐘監測生命徵象（重點是血壓——需控制以防再出血、心率、呼吸與意識），並可同步通知醫師啟動緊急 CT 與血壓控制（如 nicardipine、labetalol）。其他選項：C 止痛雖必要但應在評估後給予；B 床頭抬高 30 度為輔助性處置；C 安靜環境為支持性護理，無法取代生命徵象的密切監測。
Subarachnoid hemorrhage (SAH) is a neurological emergency with a very high risk of rebleeding. The priority nursing action is D: monitoring vital signs every 15 minutes (with particular focus on blood pressure — which must be controlled to prevent rebleeding — along with heart rate, respirations, and level of consciousness), and concurrently notifying the physician to initiate emergency CT and blood pressure control (e.g., nicardipine, labetalol). Regarding the other options: A — analgesia is appropriate but only after assessment; B — head-of-bed elevation to 30° is a supportive measure; C — a quiet environment provides supportive care but cannot replace close vital sign monitoring.
台美均強調神經監測，美國專科護理師在急性期介入更積極，台灣則多由神經外科醫師主導立即性決策。