一名 55 歲高血壓病史病患主訴突發嚴重頭痛與視力模糊。血壓 210/130 mmHg。護理師應優先採取何種措施？
A 55-year-old client with a history of hypertension reports a sudden onset of severe headache and blurred vision. Blood pressure is 210/130 mmHg. Which action is the priority for the nurse?
- AInitiate IV access and prepare for a titratable vasodilator✓ 正解建立靜脈通路並準備可調控之血管擴張劑
- BAdminister an oral antihypertensive medication給予口服降血壓藥物
- CPlace the client in a high-Fowler's position將病人置於高福勒氏體位
- DObtain a complete neurologic assessment進行完整的神經學評估
此個案呈現高血壓急症（Hypertensive Emergency），需立即降低血壓以防止末梢器官損傷。口服藥物起效太慢，體位改變僅是輔助。緊急情況下，建立靜脈通路以便使用如 Nitroprusside 或 Labetalol 等可滴定血管擴張劑是當務之急，以精確控制下降幅度，避免灌流不足。
This client presents with hypertensive emergency, requiring immediate lowering of blood pressure to prevent end-organ damage. Oral medications act too slowly, and positional changes are only supportive. In an emergency, the priority is to establish IV access so that a titratable vasodilator such as nitroprusside or labetalol can be used to precisely control the rate of pressure reduction and avoid hypoperfusion.
美國常規使用持續性靜脈輸注藥物監測，台灣在基層病房對此類高血壓急症多轉入 ICU 或加護單位進行監測。