一名 55 歲高血壓病史病患，突發劇烈頭痛及視力模糊，血壓 210/130 mmHg。護理師應優先採取的行動為何？
A 55-year-old client with a history of hypertension reports a sudden onset of severe headache and blurred vision. Blood pressure is 210/130 mmHg. Which nursing action is the priority?
- AAdminister the client's scheduled oral antihypertensive medication將話題轉移到較愉快的事物
- BPerform a comprehensive neurological assessment告訴病人：「別擔心，一切都會沒事的」
- CInitiate an intravenous line for titration of vasoactive medications✓ 正解運用治療性沉默，讓病人表達感受
- DPlace the client in a high-Fowler's position鼓勵病人壓抑眼淚
此為高血壓危象（Hypertensive Crisis），目標在於快速控制血壓以保護器官。靜脈注射降血壓藥物是臨床治療指引中的首選，能即時調整劑量以避免血壓下降過快造成的組織缺血。口服藥物起效太慢，體位僅是輔助，神經評估雖重要但需在建立給藥途徑後進行。
This is a hypertensive crisis, and the goal is to rapidly control blood pressure in order to protect end organs. Intravenous antihypertensive medication is the first-line choice in clinical guidelines because it allows immediate titration of the dose to avoid tissue ischemia from rapid blood pressure drops. Oral medications act too slowly; positioning is only supportive; and although neurological assessment is important, it should be performed after establishing the medication route.
美國護理師在重症單位常有 protocol 可自行給予降壓藥，台灣通常需醫師到場評估後開立醫囑方可給藥。