一名 55 歲高血壓病史病人主訴嚴重頭痛及視力模糊，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 severe headache and blurred vision. The nurse notes a blood pressure of 210/130 mmHg. Which action is the priority?
- APlace the client in a high-Fowler's position✓ 正解將病人置於高福勒氏體位
- BPrepare the client for rapid neurological assessment準備病人進行快速的神經系統評估
- CAdminister an oral antihypertensive medication給予口服降血壓藥物
- DObtain an EKG to assess for ischemic changes進行心電圖檢查以評估缺血變化
此個案呈現高血壓急症（Hypertensive Crisis），優先採取高半坐臥位（High-Fowler's）可減輕心臟負擔並降低腦部充血壓力。同時應準備靜脈注射降壓藥而非口服藥，因為口服藥吸收過慢，無法立即緩解器官損傷風險。神經學評估與心電圖皆為後續評估步驟。
This client presents with a hypertensive crisis. The priority is to place the client in a high-Fowler's position to reduce cardiac workload and lower cerebral congestive pressure. Intravenous antihypertensives, rather than oral agents, should be prepared, because oral absorption is too slow to immediately relieve the risk of end-organ damage. Neurological assessment and ECG are subsequent evaluation steps.
美國醫院針對高血壓急症有明確 Protocol 執行 IV 降壓；台灣需視醫囑執行，護理師應主動提醒緊急醫療處理。