一位 55 歲高血壓病史病患主訴突發嚴重頭痛及視力模糊，護理師測得血壓 210/120 mmHg。應優先採取何種措施？
A 55-year-old client with a history of hypertension reports a sudden, severe headache and blurred vision. The nurse notes a blood pressure of 210/120 mmHg. Which action is the priority?
- APlace the client in a high-Fowler’s position將病人置於高福勒氏臥位
- BObtain a complete neurologic assessment✓ 正解進行完整的神經學評估
- CPrepare for a stat CT scan of the head準備立即進行頭部電腦斷層掃描
- DAdminister an oral antihypertensive medication給予口服抗高血壓藥物
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。現有選項中 D「完整神經學評估」為合理優先：210/120 + 頭痛 + 模糊視覺暗示腦血管事件可能（如顱內出血、高血壓性腦病），需評估意識、瞳孔、肢體力與感覺以引導後續處置。其他選項：A 半坐臥位為支持性處置；B 口服降壓藥對急症太慢；C 頭部 CT 為診斷步驟，需在初步評估後才安排。
In hypertensive emergency (BP ≥180/120 with signs of end-organ damage), the true priority action is to administer an IV antihypertensive (such as labetalol or nicardipine) immediately, but this question does not include that option. Among the given choices, B, a comprehensive neurological assessment, is a reasonable priority: a BP of 210/120 with headache and blurred vision suggests a possible cerebrovascular event (such as intracranial hemorrhage or hypertensive encephalopathy), and assessing level of consciousness, pupils, and motor and sensory function helps guide subsequent management. Other options: A, high-Fowler's position, is supportive only; B, an oral antihypertensive, is too slow for emergency management; C, a head CT, is a diagnostic step that should be arranged after initial assessment.
美國護理師常依據急症流程給予適當體位，台灣臨床上處理 hypertensive emergency 需高度依賴醫師醫囑調整給藥路徑。