一名 55 歲高血壓病史病人，突發嚴重頭痛、視力模糊，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 is presenting with sudden onset of severe headache, blurred vision, and a blood pressure of 210/120 mmHg. Which nursing action is the priority?
- AElevate the head of the bed to 45 degrees✓ 正解將床頭抬高 45 度
- BPerform a comprehensive neurological assessment進行全面的神經系統評估
- CAdminister the prescribed oral antihypertensive medication給予處方的口服抗高血壓藥物
- DObtain an EKG to rule out myocardial infarction進行心電圖檢查以排除心肌梗塞
此個案呈現高血壓危象（Hypertensive Crisis），首要目標是減輕腦部壓力並監測生命徵象。抬高床頭有助於降低顱內壓並改善腦部靜脈回流，是緊急處置的第一步。藥物治療通常優先考慮靜脈注射，口服藥效太慢；神經評估與心電圖雖重要，但需在確保病人體位安全後進行。
This client is presenting with a hypertensive crisis. The primary goals are to reduce cerebral pressure and monitor vital signs. Elevating the head of the bed helps lower intracranial pressure and improves cerebral venous return, making it the first step of emergency management. Pharmacologic therapy typically requires intravenous administration, since oral medications act too slowly. Neurologic assessment and EKG are important but should follow after ensuring safe positioning.
美國護理師常依據 ICU protocol 主動調整靜脈輸注藥物速率，台灣則多需嚴格醫囑遵照執行。