一名 55 歲高血壓病史病患主訴突發嚴重頭痛。護理師測得血壓為 210/120 mmHg。護理師應優先執行哪項措施？
A 55-year-old client with a history of hypertension reports a sudden, severe headache. The nurse measures a blood pressure of 210/120 mmHg. Which action should the nurse take first?
- AObtain an ECG取得心電圖
- BAdminister an oral antihypertensive medication給予口服降壓藥物
- CPlace the client in a high Fowler's position讓病人採取高福勒氏臥位
- DPerform a neurological assessment✓ 正解進行神經學評估
高血壓急症（hypertensive emergency, BP ≥180/120 + 末端器官損害徵象）優先動作為立即評估與啟動降壓措施。本題病人 BP 210/120 + 嚴重頭痛提示腦血管事件可能（如顱內出血、高血壓性腦病），現有選項中 D「神經學評估」為合理優先：評估意識、瞳孔、肢體力以引導後續處置（IV 降壓藥、影像）。其他選項：C 高坐臥位為支持性處置；B 口服降壓藥對急症太慢；C 心電圖可同步進行但對神經症狀非最直接。
A hypertensive emergency (BP ≥180/120 with end-organ damage) requires immediate evaluation and pressure-lowering interventions. This client's BP of 210/120 with a severe headache suggests a possible cerebrovascular event (e.g., intracranial hemorrhage, hypertensive encephalopathy). Among the options, D (neurological assessment) is the reasonable priority: assessing level of consciousness, pupils, and motor function guides subsequent care (IV antihypertensives, imaging). A (high-Fowler's position) is only supportive; B (oral antihypertensive) is too slow for an emergency; C (ECG) may be done in parallel but is not the most direct for neurologic symptoms.
美台臨床對於高血壓危象處置趨勢一致，但美國護理師依 protocol 給予靜脈降壓藥權限較大。