一位 55 歲有高血壓病史的病人主訴突發嚴重頭痛、視力模糊及頸部僵硬。血壓 210/120 mmHg。下列哪項護理措施為最高優先？
A 55-year-old client with a history of hypertension reports a sudden, severe headache, blurred vision, and neck stiffness. Blood pressure is 210/120 mmHg. Which nursing action is the highest priority?
- AObtain a complete blood count進行全血球計數
- BAdminister an antihypertensive medication as ordered依醫囑給予抗高血壓藥物
- CPlace the client in a semi-Fowler's position將病人置於半坐臥位
- DPerform a neurological assessment✓ 正解進行神經學評估
此個案呈現高血壓急症併發腦出血徵兆（頭痛、頸部僵硬），需先確認神經功能狀態（GCS、瞳孔反應）以評估顱內壓變化。B 是治療步驟，但在評估神經功能前先行給藥可能掩蓋臨床變化。C 雖可降低顱內壓，但評估仍應優先。A 對急性期診斷無直接幫助。
This patient is presenting with a hypertensive emergency complicated by signs of intracerebral hemorrhage (headache, neck stiffness); the priority is to assess neurologic status (GCS, pupillary response) to evaluate changes in intracranial pressure. Option B is a treatment step, but administering medication before assessing neurologic function may mask clinical deterioration. Option C may help reduce ICP, but assessment should still take priority. Option A is not directly useful for diagnosis in the acute phase.
美國護理師常依院內高血壓急症處理流程（Protocol）預先給藥，台灣多需醫師立即開立醫囑。