— 生理適應 · EASY · MCQ —
一位 55 歲高血壓病史病人入院時血壓 190/110 mmHg，護理師評估時應優先注意哪項臨床表徵？
A 55-year-old client with a history of hypertension is admitted with a blood pressure of 190/110 mmHg. Which clinical manifestation should the nurse prioritize during assessment?
- AModerate increase in urinary output尿量中度增加
- BBilateral pitting pedal edema雙側足踝壓陷性水腫
- CReports of a mild frontal headache主訴輕微的前額頭痛
- DNumbness and tingling in the left arm✓ 正解左臂麻木和刺痛
— Explanation · 中文詳解 —
高血壓急症時，神經系統表現（如單側肢體麻木、無力）暗示可能發生急性腦血管病變（中風），需立即介入以減少永久性神經受損。其他選項如頭痛為常見症狀，但非急性中風之急迫神經徵象；水腫反映慢性狀態；尿量增加則多為利尿劑效應。
In a hypertensive emergency, neurologic manifestations such as unilateral numbness or weakness suggest acute cerebrovascular events (stroke) and require immediate intervention to limit permanent neurologic injury. Other findings such as headache are common but less acute; pitting edema reflects a chronic condition; increased urine output usually reflects diuretic effect.
✦ 台美臨床差異
美台臨床皆重視神經徵象，但美國急診分流（Triage）針對 Stroke Scale 評估有更明確的流程與時效性要求。