一位 55 歲高血壓病史病人主訴突發性劇烈頭痛及視力模糊，血壓 210/130 mmHg。護理師應優先採取何項措施？
A 55-year-old client with a history of hypertension reports a sudden, severe headache and blurred vision. The blood pressure is 210/130 mmHg. Which action is the priority?
- APerform a neurological assessment進行神經學評估
- BObtain an ECG取得心電圖
- CAdminister an oral antihypertensive medication給予口服降壓藥物
- DPlace the client in a high-Fowler's position✓ 正解將病人置於高福勒氏臥位
此為高血壓急症（Hypertensive Crisis），優先採取高半坐臥姿勢（High-Fowler's）可減輕心臟負載並協助呼吸及腦部血液動力平衡。口服藥物起效慢不適用於急症；心電圖與神經評估雖重要，但應在穩定姿勢與啟動急救流程後進行。
This presentation is a hypertensive emergency (severe BP elevation with end-organ symptoms such as headache and visual changes). Placing the client in High-Fowler's position decreases venous return and intracranial pressure, providing immediate (though temporary) hemodynamic support while IV antihypertensives are prepared. Oral agents act too slowly for an emergency. ECG and neurologic assessment are important but follow stabilization.
美國護理師常依據特定 protocol 直接執行高半坐臥姿勢並通知團隊，台灣臨床亦同，但在高血壓急症處置上，台灣醫師參與決策權重較高。