一名 55 歲高血壓病史病患主訴突發嚴重頭痛與視力模糊。血壓為 210/130 mmHg。護理師首要採取哪項行動？
A 55-year-old client with a history of hypertension reports a sudden, severe headache and blurred vision. The blood pressure is 210/130 mmHg. Which nursing action is the priority?
- AMaintain the head of the bed at 30 to 45 degrees將床頭抬高 30 至 45 度
- BObtain an EKG to assess for cardiac ischemia進行心電圖檢查以評估心肌缺血
- CAdminister oral antihypertensive medication as ordered依醫囑給予口服降血壓藥物
- DPrepare the client for immediate IV vasodilator administration✓ 正解準備病人立即接受靜脈血管擴張劑給藥
此個案呈現高血壓急症（Hypertensive Emergency）表現，目標器官已受損（視力模糊、嚴重頭痛），需緊急靜脈給予血管擴張劑以平穩降低平均動脈壓，防止腦出血或急性腎損壞。口服藥物起效太慢，且體位調整無法控制血壓，EKG 雖然重要但非最緊急穩定手段。
This presentation reflects hypertensive emergency with end-organ damage (blurred vision, severe headache). Emergency IV vasodilators are required to safely lower mean arterial pressure and prevent intracerebral hemorrhage or acute kidney injury. Oral medications act too slowly; positioning cannot control blood pressure; ECG is important but not the immediate stabilization measure.
美國醫護對於高血壓急症常有嚴格的 ICU Protocol，台灣臨床對高血壓急症的給藥轉移權限高度依賴醫師開立，護理師需密切監測輸注反應。