— 生理適應 · HARD · MCQ —
一名 45 歲高血壓病史病患主訴突然劇烈頭痛及視力模糊，血壓 210/130 mmHg。護理師應優先採取何種措施？
A 45-year-old client with a history of hypertension reports a sudden onset of severe headache and blurred vision. The blood pressure is 210/130 mmHg. Which action should the nurse prioritize?
- AAdminister an oral antihypertensive tablet給予口服抗高血壓藥片
- BObtain an EKG to assess for cardiac damage進行心電圖檢查以評估心臟損害
- CElevate the head of the bed to 45 degrees將床頭抬高 45 度
- DPrepare for rapid-acting intravenous antihypertensive therapy✓ 正解準備快速作用的靜脈抗高血壓治療
— Explanation · 中文詳解 —
此個案呈現高血壓急症 (Hypertensive Emergency)，收縮壓超過 180 或舒張壓超過 120，伴隨急性器官損傷（視力模糊/嚴重頭痛）。首要目標是透過靜脈輸注迅速降壓，避免腦出血或心肌梗塞。口服藥物起效太慢，不可作為首選。
This patient is presenting with a hypertensive emergency: systolic blood pressure above 180 or diastolic above 120 with acute end-organ damage (blurred vision/severe headache). The primary goal is to lower blood pressure rapidly with intravenous therapy to prevent cerebral hemorrhage or myocardial infarction. Oral medications act too slowly and cannot be used as the first-line agent.
✦ 台美臨床差異
美國護理師常依據 ICU 醫囑滴定點滴；台灣臨床醫師更傾向親自監控高危藥物滴注速率。