一位 55 歲高血壓病史病患主訴劇烈頭痛、視力模糊及意識混亂，血壓 220/130 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 confusion. Blood pressure is 220/130 mmHg. What is the nurse's priority action?
- AElevate the head of the bed to 45 degrees將床頭抬高至 45 度
- BInitiate continuous cardiac monitoring開始連續心電圖監測
- CAdminister oral antihypertensive medication給予口服抗高血壓藥物
- DPrepare for rapid-acting IV antihypertensive therapy✓ 正解準備快速作用的靜脈注射抗高血壓治療
此個案呈現高血壓急症 (Hypertensive Emergency)，關鍵在於器官損傷風險。必須迅速使用 IV 降壓藥物（如 Nitroprusside 或 Labetalol）控制血壓，預防腦血管意外或腎衰竭。C 選項口服藥物起效太慢；A 雖可緩解頭痛但非最關鍵的降壓處置；B 雖必要但非解決急性高壓的核心。
This presentation indicates a hypertensive emergency with end-organ involvement. Rapid IV antihypertensive therapy (e.g., nitroprusside or labetalol) is required to titrate blood pressure quickly and prevent stroke or renal failure. Oral medications act too slowly (C); raising the head (A) eases headache but does not lower systemic BP; cardiac monitoring (B) is needed but not the central intervention.
美國臨床護理師常依嚴格的 SBP/DBP 降壓 Protocol 執行，台灣臨床多依賴醫師開立 IV 藥物後執行，且對於使用這類強效降壓藥的監測頻率要求極高。