一位 55 歲高血壓病史病患主訴突發嚴重頭痛及視力模糊，血壓 210/130 mmHg。護理師優先採取的行動為何？
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. What is the nurse's priority action?
- AAssess the client's neurological status✓ 正解評估病人的神經狀態
- BObtain an EKG進行心電圖檢查
- CAdminister IV antihypertensive medication as ordered依醫囑靜脈注射抗高血壓藥物
- DPlace the client in a high-Fowler's position將病人置於高福勒氏臥位
此個案呈現高血壓急症 (Hypertensive Emergency) 特徵，需先評估神經學狀態以排除腦出血或高血壓腦病變。雖然降壓藥物至關重要，但需先確認意識層次及神經損害程度，此資訊決定後續降壓速度及用藥選擇，確保安全。
This client presents with features of a Hypertensive Emergency. The neurological status must be assessed first to rule out cerebral hemorrhage or hypertensive encephalopathy. Although antihypertensive medication is critical, the level of consciousness and degree of neurological impairment must be confirmed first, as this information determines the rate of subsequent blood pressure reduction and the choice of agent, ensuring safety.
美國醫院常見急症護理程序包含立即執行 GCS 評分，台灣臨床多優先將病人置於加護病房監測，護理師需配合醫師給予降壓藥。