— 生理適應 · HARD · MCQ —
一名 55 歲高血壓病史病患主訴嚴重頭痛與視力模糊，血壓為 210/130 mmHg。護理師優先採取之行動為何？
A 55-year-old client with a history of hypertension reports severe headache and blurred vision. The BP is 210/130 mmHg. Which nursing action is the priority?
- AAdminister the prescribed oral antihypertensive medication給予處方的口服抗高血壓藥物
- BObtain an EKG to assess for cardiac ischemia進行心電圖檢查以評估心肌缺血
- CElevate the head of the bed to 45 degrees✓ 正解將床頭抬高 45 度
- DPerform a neurological assessment including pupil reaction進行包含瞳孔反應的神經學評估
— Explanation · 中文詳解 —
此為高血壓急症 (Hypertensive Emergency)，首要任務是減輕腦部充血與高血壓帶來的器官損害。抬高床頭可協助降低腦內壓並減緩頭痛。B 與 D 為評估性動作，雖重要但必須先採取物理性減壓措施。口服藥物藥效太慢，不適合急症處理，通常需靜脈注射降壓藥。
This is a hypertensive emergency. The priority is reducing cerebral congestion and end-organ damage. Elevating the head of the bed helps lower intracranial pressure and ease headache. EKG (B) and neuro assessment (D) are evaluations—important but secondary to immediate physical decompression. Oral antihypertensives are too slow; IV agents are typically required.
✦ 台美臨床差異
美國醫院有嚴謹的高血壓急症靜脈注射給藥流程；台灣臨床護理師常需等待醫師針對靜脈降壓藥給予明確醫囑。