— 生理適應 · MEDIUM · MCQ —
一名 55 歲高血壓病史病患入院，血壓 180/110 mmHg。下列哪項評估發現是向醫師報告的最高優先事項？
A 55-year-old client with a history of hypertension is admitted with a blood pressure of 180/110 mmHg. Which assessment finding is the highest priority to report to the healthcare provider?
- AReports of a severe occipital headache and blurred vision✓ 正解主訴嚴重的枕部頭痛及視力模糊。
- BSerum potassium level of 3.8 mEq/L血清鉀濃度為 3.8 mEq/L。
- CHeart rate of 88 beats per minute心率為每分鐘 88 次。
- DBilateral pedal edema雙側足部水腫。
— Explanation · 中文詳解 —
高血壓危象（Hypertensive Crisis）的目標在於預防標的器官損傷。嚴重頭痛伴隨視力模糊暗示腦部高壓或潛在的高血壓性腦病變，屬於緊急情況，需立即介入以防止中風或不可逆的神經損傷。其餘選項雖需監測，但不具備立即威脅生命之急迫性。
The goal in hypertensive crisis is to prevent end-organ damage. Severe headache with blurred vision suggests increased intracranial pressure or potential hypertensive encephalopathy—an emergency requiring immediate intervention to prevent stroke or irreversible neurological injury. Other findings require monitoring but lack immediate life-threatening urgency.
✦ 台美臨床差異
美國護理師依據 SBAR 溝通模式，對於器官受損徵象需緊急啟動醫師聯繫；台灣多由護理師先評估並給予 PRN 降壓藥再監測。