一名 45 歲高血壓病史病患因血壓 210/120 mmHg 入院，主訴劇烈頭痛與視力模糊。護理師的首要行動為何？
A 45-year-old client with a history of hypertension is admitted with a blood pressure of 210/120 mmHg and reports a severe headache and blurred vision. What is the nurse's priority action?
- APerform a neurological assessment進行神經系統評估
- BAdminister oral anti-hypertensive medication給予口服抗高血壓藥物
- CObtain an ECG取得心電圖（ECG）
- DPlace the client in a high-Fowler’s position✓ 正解將病人置於高福勒氏臥位（High-Fowler’s position）
此個案呈現高血壓危象（Hypertensive Crisis）徵象，優先處理應考量病人舒適度與呼吸支持。採取高半坐臥位（High-Fowler’s）不僅能減輕頭部血管內壓力，對於這類伴隨視力模糊與頭痛的病人，適當的體位能減少顱內壓升高的影響，並方便護理師觀察呼吸狀況。高血壓危象首要穩定生命徵象，避免器官受損，後續才進行藥物治療或進一步影像檢查。神經評估固然重要，但需先安排合適體位來減輕症狀。口服藥物起效太慢，通常需要靜脈給藥。心電圖則是用於排除心肌缺血，非第一時間處理之首要項目。
This case shows signs of a hypertensive crisis, and initial management should consider patient comfort and respiratory support. Placing the client in a high-Fowler's position not only reduces vascular pressure in the head but, for patients with accompanying blurred vision and headache, an appropriate position can lessen the impact of rising intracranial pressure and allow the nurse to observe respiratory status more easily. In a hypertensive crisis, the priority is to stabilize vital signs and prevent organ damage, with drug therapy or further imaging to follow. Neurological assessment is also important, but an appropriate position should be arranged first to relieve symptoms. Oral medications act too slowly; intravenous administration is typically required. An ECG is used to rule out myocardial ischemia and is not the first action.
美國醫院針對高血壓急症常有標準的降壓 protocol，護理師在醫囑範圍內可執行；台灣則高度依賴主治醫師決策，護理師在給藥前須確認醫囑頻率。