一名 55 歲高血壓病史病患主訴劇烈頭痛、視力模糊及噁心，血壓 210/120 mmHg。護理師應優先採取什麼行動？
A 55-year-old client with a history of hypertension reports severe headache, blurry vision, and nausea. Blood pressure is 210/120 mmHg. Which action should the nurse take first?
- APerform a neurological assessment✓ 正解進行神經學評估
- BAdminister the prescribed oral antihypertensive medication給予處方的口服抗高血壓藥物
- CElevate the head of the bed to 45 degrees將床頭抬高至 45 度
- DPrepare for immediate intravenous antihypertensive therapy準備立即進行靜脈注射抗高血壓治療
此個案呈現高血壓急症（Hypertensive Emergency）症狀。護理首要為執行神經學評估（如 GCS、瞳孔反應），以確認有無器官損傷（如中風或腦病變）。C 雖有幫助但不夠緊急；B 對於嚴重急性症狀口服藥太慢；D 為醫囑行為，應先進行評估供醫師決策參考。
This case presents the symptoms of a hypertensive emergency. The nurse's priority is to perform a neurological assessment (such as GCS and pupillary response) to determine whether end-organ damage (such as stroke or encephalopathy) is present. Option C is helpful but not urgent enough; Option B is too slow because oral medication is inadequate for severe acute symptoms; and Option D involves medical orders, so the assessment should be done first to inform the physician's decision-making.
美國護理師依 protocol 給予 IV 降壓藥較常見；台灣臨床多由醫師親自評估後開立給藥。