一位 45 歲有高血壓病史的病人主訴突發性劇烈頭痛、視力模糊及噁心，血壓 210/120 mmHg。護理師首要行動為何？
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 210/120 mmHg. Which action is the priority for the nurse?
- APerform a comprehensive neurological assessment進行全面的神經系統評估
- BPlace the client in a semi-Fowler's position將病人置於半坐臥位
- CAdminister an oral antihypertensive medication給予口服降壓藥物
- DPrepare for immediate administration of IV vasodilators✓ 正解準備立即靜脈給藥血管擴張劑
此個案呈現高血壓急症（Hypertensive Emergency）症狀，且伴隨器官損傷風險。緊急狀況下需靜脈給予血管擴張劑以快速降低血壓，避免進一步的腦血管或心血管損傷。口服藥物作用慢，無法控制此危險血壓；擺位雖可緩解舒適度，但非優先；神經評估是重要步驟，但必須先處理過高的生命徵象。
This patient presents with symptoms of a hypertensive emergency and is at risk for end-organ damage. In this urgent situation, intravenous vasodilators must be given to lower blood pressure rapidly and prevent further cerebrovascular or cardiovascular injury. Oral medications act too slowly to control this dangerous blood pressure level; positioning may improve comfort but is not the priority; and although neurological assessment is important, the dangerously elevated vital signs must be addressed first.
美國護理師在重症監護室可依據醫囑執行滴定給藥，台灣臨床此類急症通常需醫師親自評估後再行靜脈給藥。