一名 55 歲高血壓病史病患入院時血壓 180/110 mmHg，伴隨劇烈頭痛。護理師應優先採取何種行動？
A 55-year-old client with a history of hypertension is admitted with a blood pressure of 180/110 mmHg and a severe headache. Which nursing action is the priority?
- ADocument the blood pressure in the chart將血壓記錄於病歷中。
- BAdminister the scheduled oral antihypertensive medication給予預定之口服降壓藥物。
- CEncourage the client to rest in a dark room鼓勵病人在昏暗房間中休息。
- DPerform a neurological assessment✓ 正解進行神經學評估。
高血壓危象（Hypertensive crisis）定義為血壓極高（通常收縮壓 >180 或舒張壓 >120 mmHg）且伴隨器官受損的徵兆。劇烈頭痛是腦部受損（如高血壓腦病變、腦出血）的警訊。護理師必須優先執行神經學評估（Neurological assessment），以判斷病人的意識狀態、瞳孔反應及是否有神經功能缺損，這是評估危急程度的首要任務。
Hypertensive crisis is defined as severely elevated blood pressure (usually systolic >180 mmHg or diastolic >120 mmHg) accompanied by signs of end-organ damage. A severe headache is a warning sign of cerebral involvement (such as hypertensive encephalopathy or intracerebral hemorrhage). The nurse must prioritize a neurological assessment to evaluate the client's level of consciousness, pupillary responses, and any focal neurologic deficits, which is essential for determining the urgency of the situation.