一名 55 歲高血壓病史病患入院，血壓 180/110 mmHg 且伴隨劇烈頭痛。護理師應優先採取何項措施？
A 55-year-old client with a history of hypertension is admitted with a blood pressure of 180/110 mmHg and a severe headache. Which nursing action is the highest priority?
- AAdminister the prescribed antihypertensive medication給予處方之降血壓藥物
- BPerform an electrocardiogram進行心電圖檢查
- CAssess the client's level of consciousness and neurological status✓ 正解評估病人之意識水準與神經狀態
- DPlace the client in a supine position將病人置於仰臥位
高血壓急症（Hypertensive Emergency）的核心危險在於標的器官損傷（Target Organ Damage），特別是腦部。劇烈頭痛可能暗示腦水腫、高血壓腦病變或中風。護理師首要任務是評估神經學狀態（如意識程度、瞳孔、肢體力量），以判斷是否存在立即性的腦部損傷風險，這比單純給予降壓藥更具臨床優先權。
The central danger of a hypertensive emergency is target organ damage, particularly to the brain. A severe headache may indicate cerebral edema, hypertensive encephalopathy, or stroke. The nurse's first task is to assess neurological status (level of consciousness, pupils, and motor strength) to determine whether there is an immediate risk of brain injury; this takes clinical precedence over simply administering an antihypertensive medication.