— 生理適應 · HARD · MCQ —
一名 45 歲高血壓病史病患主訴突發性劇烈頭痛、視力模糊，血壓為 210/130 mmHg。下列哪項評估為首要？
A 45-year-old client with a history of hypertension reports a sudden, severe headache, blurred vision, and a blood pressure of 210/130 mmHg. Which assessment is the priority?
- AObtain an EKG to check for myocardial strain取得心電圖以檢查心肌應變
- BAsk the client about medication adherence詢問案主關於藥物依從性
- CPerform a physical exam to check for peripheral edema進行身體檢查以檢查周邊水腫
- DAssess neurological status (level of consciousness, pupillary reaction)✓ 正解評估神經狀態（意識層次、瞳孔反應）
— Explanation · 中文詳解 —
此為高血壓急症（Hypertensive Emergency），極高血壓伴隨器官受損風險（頭痛、視力模糊暗示腦部併發症）。優先評估神經學狀態以確立是否有急性中風或高血壓腦病變徵兆，這是決定後續醫療介入急迫性的關鍵。
This is a hypertensive emergency: extremely elevated blood pressure with risk of end-organ damage (the headache and blurred vision suggest cerebral involvement). The priority is to assess neurological status to identify any signs of acute stroke or hypertensive encephalopathy, which is the key step in determining the urgency of subsequent medical intervention.
✦ 台美臨床差異
美國護理師在重症單位常執行標準化 NIHSS 評估；台灣護理師則常由醫師執行複雜的神經評估。