一名 55 歲高血壓病史病人主訴突然嚴重頭痛與視力模糊，血壓為 210/130 mmHg。護理師應優先採取的行動為何？
A 55-year-old client with a history of hypertension reports a sudden onset of severe headache and blurred vision. The blood pressure is 210/130 mmHg. Which action is the priority for the nurse?
- AObtain an ECG取得心電圖
- BAdminister oral antihypertensive medication給予口服抗高血壓藥物
- CPrepare for rapid-acting IV antihypertensive therapy✓ 正解準備快速作用的靜脈抗高血壓治療
- DElevate the head of the bed to 45 degrees將床頭抬高至 45 度
此個案呈現高血壓急症 (Hypertensive Emergency)，收縮壓超過 180 或舒張壓超過 120 並伴隨標的器官損傷症狀（頭痛、視力模糊）。首要目標是透過靜脈輸注強效降壓藥控制血壓，預防腦血管意外或進一步器官損傷。口服藥物起效太慢，且無法在緊急狀況下精確滴定。
This presentation represents a hypertensive emergency, defined as systolic BP greater than 180 or diastolic BP greater than 120 accompanied by signs of target-organ damage (headache, blurred vision). The priority goal is to control blood pressure with a potent intravenous antihypertensive agent to prevent cerebrovascular events and further organ injury. Oral medications have too slow an onset and cannot be precisely titrated in emergencies.
美台臨床皆視此為急症，美國護理師常依 Protocol 監測並執行，台灣則需醫師開立靜脈給藥醫囑後執行。