一名 55 歲高血壓病史病患主訴嚴重頭痛及視力模糊，測得血壓 210/120 mmHg。護理師首要採取哪項行動？
A 55-year-old client with a history of hypertension reports severe headache and blurred vision. The blood pressure is 210/120 mmHg. Which nursing action is the highest priority?
- AObtain an EKG to check for myocardial strain進行心電圖檢查以評估心肌負擔
- BPrepare for the administration of intravenous antihypertensive agents✓ 正解準備給予靜脈注射抗高血壓藥物
- CElevate the head of the bed to 30 degrees將床頭抬高 30 度
- DAdminister an oral antihypertensive medication給予口服抗高血壓藥物
此個案表現為高血壓急症（Hypertensive Emergency），目標是透過靜脈注射藥物逐步降低血壓以保護標的器官。頭高位（C）雖可協助但非治療核心；口服藥物（D）作用過慢且無法精確滴定；心電圖（A）雖重要但優先順序次於藥物介入。
This client is presenting with a hypertensive emergency; the goal is to lower the blood pressure gradually with intravenous medications in order to protect end organs. The head-elevated position (C) may be supportive but is not the core treatment; an oral medication (D) acts too slowly and cannot be precisely titrated; ECG monitoring (A), although important, is lower priority than pharmacologic intervention.
美國護理師依醫囑對危急值處理有較多彈性；台灣對於高血壓急症常要求醫師親自到場下令並監控。