一位 55 歲高血壓病史病患主訴突發嚴重頭痛、視力模糊及噁心。血壓為 210/120 mmHg。護理師應優先採取何種行動？
A 55-year-old client with a history of hypertension reports a sudden, severe headache, blurred vision, and nausea. The blood pressure is 210/120 mmHg. Which action is the priority for the nurse?
- APlace the client in a high-Fowler’s position將病人置於高福勒氏臥位
- BAdminister an oral antihypertensive medication給予口服抗高血壓藥物
- CObtain a complete neurologic assessment✓ 正解進行完整的神經學評估
- DPrepare the client for immediate admission to the ICU準備病人立即入住加護病房
高血壓急症（hypertensive emergency, BP ≥180/120 + 末端器官損害徵象）的真正優先動作為立即給予 IV 降壓藥（如 labetalol、nicardipine），但本題未提供此選項。在現有選項中 C「完整神經學評估」是合理優先：210/120 + 頭痛+模糊視覺+噁心提示可能腦血管事件（如顱內出血、高血壓性腦病），需評估意識、瞳孔、肢體力與感覺，作為後續處置的依據。其他選項：B 口服降壓藥對急症太慢；B 半坐臥位屬支持性處置；D 入 ICU 為後續安置非當下動作。
The true priority action in a hypertensive emergency (BP ≥ 180/120 with signs of end-organ damage) is the immediate administration of an IV antihypertensive agent (for example, labetalol or nicardipine), but this option is not provided here. Among the given options, C, a complete neurological assessment, is a reasonable priority: a BP of 210/120 with headache, blurred vision, and nausea suggests a possible cerebrovascular event (such as intracranial hemorrhage or hypertensive encephalopathy), so evaluating level of consciousness, pupils, motor and sensory function provides the basis for subsequent management. The other options: oral antihypertensives (B) are too slow for an emergency; semi-Fowler's positioning (A) is only supportive; and ICU admission (D) is a downstream disposition, not the immediate action.
美國高血壓急症照護常有標準 protocol 允許護理師先放置體位並準備 IV，台灣則高度依賴醫囑給藥。