一位 55 歲高血壓病史病患出現突發劇烈頭痛及視力模糊，血壓 220/130 mmHg。護理師首要行動為何？
A 55-year-old client with a history of hypertension reports a sudden onset of severe headache and blurred vision. Blood pressure is 220/130 mmHg. What is the nurse's priority action?
- AObtain an EKG to assess for ischemia進行心電圖檢查以評估缺血情形
- BAdminister an oral antihypertensive medication給予口服降血壓藥物
- CPrepare for rapid-acting IV antihypertensive therapy✓ 正解準備快速作用的靜脈注射降血壓治療
- DElevate the head of the bed to 45 degrees將床頭抬高至 45 度角
此為高血壓急症（Hypertensive Emergency），目標是將血壓在數小時內逐步降低，以防器官損害。口服藥物起效太慢，且無法精確滴定。抬高床頭是物理輔助，但非核心處置。急需靜脈給藥（如 Labetalol 或 Nicardipine）以精確控制藥量並密切監測器官血流。
This is a hypertensive emergency. The goal is to gradually reduce blood pressure within hours to prevent end-organ damage. Oral medications have too slow an onset and cannot be precisely titrated. Elevating the head of the bed is a physical adjunct but not a core intervention. Rapid IV administration (such as labetalol or nicardipine) is urgently needed to precisely control dosage and closely monitor organ perfusion.
美台臨床對於高血壓急症的藥物選擇類似，台灣醫師對於急性期藥物調整較為謹慎，多由醫師親自操作調配。