一名 45 歲高血壓病史患者入院，血壓 210/120 mmHg，自述嚴重頭痛及視力模糊。護理師應優先採取哪項行動？
A 45-year-old client with a history of hypertension is admitted with a blood pressure of 210/120 mmHg and reports a severe headache and blurred vision. Which nursing action is the highest priority?
- AAdminister ordered antihypertensive medication✓ 正解給予醫囑指示的降壓藥物
- BInitiate continuous cardiac monitoring開始連續心臟監測
- CElevate the head of the bed to 45 degrees將床頭抬高 45 度
- DObtain a neurological assessment進行神經學評估
高血壓急症（hypertensive emergency, BP ≥180/120 + 末端器官損害徵象）的優先護理動作是立即給予醫囑的 IV 降壓藥（如 nicardipine、labetalol、nitroprusside）。本題病人 BP 210/120 + 頭痛 + 視力模糊，提示可能腦部末端器官損害（高血壓性腦病或顱內出血），需快速降壓以防止進展。其他選項：D 神經學評估與 B 心電圖監測應同步進行；C 抬高床頭屬支持性處置，無法解決核心問題。注意降壓速度需謹慎（首小時降低 ≤25%），避免腦部缺血。
The priority nursing action in a hypertensive emergency (BP ≥180/120 plus signs of end-organ damage) is to immediately administer the ordered IV antihypertensive agent (such as nicardipine, labetalol, or nitroprusside). This client's BP of 210/120 with headache and blurred vision suggests possible cerebral end-organ damage (hypertensive encephalopathy or intracranial hemorrhage) and requires rapid blood pressure lowering to prevent progression. The other options: A. neurologic assessment and D. ECG monitoring should occur concurrently; C. elevating the head of the bed is supportive only and does not address the underlying problem. Note that BP must be lowered cautiously (≤25% reduction in the first hour) to avoid cerebral ischemia.
美國醫院針對高血壓急症常有標準化的 Rapid Response 流程與嚴格的血壓目標控制 protocol（如每 5-15 分鐘監測）。台灣臨床則較依賴醫師隨時調整靜脈注射降壓藥物（如 Nicardipine），護理師需具備熟練的幫浦設定能力與更頻繁的臨床評估。