一位 55 歲患有高血壓的個案表示突然出現劇烈頭痛，描述為「人生中最嚴重的頭痛」。護理師應優先採取哪項行動？
A 55-year-old client with a history of hypertension reports a sudden, severe headache described as the 'worst headache of my life.' Which nursing action is the priority?
- AAssess neurologic status using the Glasgow Coma Scale✓ 正解使用格拉斯哥昏迷量表評估神經狀態
- BMaintain a quiet, dark environment維持安靜、昏暗的環境
- CPrepare the client for a stat CT scan準備病人接受立即電腦斷層掃描
- DAdminister an analgesic as ordered依醫囑給予止痛藥
此個案描述「人生中最嚴重的頭痛」（thunderclap headache）是蛛網膜下腔出血（SAH）的典型徵兆。護理師必須依循護理程序，在介入檢查或給藥前，先進行全面性的神經學評估（GCS 評分），以建立基準線並監測意識狀態的惡化情況。雖然 CT 檢查（C）是診斷的首選，但護理師在執行醫囑前，必須確保病人的生理狀態（如氣道呼吸與意識）是穩定的。給予止痛藥（D）可能掩蓋症狀表現，影響醫師對病情嚴重度的判斷；環境控制（B）僅是輔助性護理措施。優先進行神經學評估能即時偵測是否有腦壓上升或腦疝風險，這是照顧此類病患時，護理師維持生理穩定的第一道防線，也是確保病人安全的核心決策。
A description of the "worst headache of my life" (a thunderclap headache) is a classic sign of subarachnoid hemorrhage (SAH). The nurse must follow the nursing process and perform a comprehensive neurological assessment (including the Glasgow Coma Scale) before initiating diagnostic tests or administering medications, in order to establish a baseline and monitor for deterioration in level of consciousness. Although a CT scan (C) is the diagnostic test of choice, the nurse must first ensure that the client is physiologically stable (airway, breathing, and consciousness) before carrying out provider orders. Administering an analgesic (D) may mask symptoms and impair the provider's evaluation of severity; environmental control (B) is only an adjunctive measure. Performing the neurological assessment first allows for prompt detection of increasing intracranial pressure or impending herniation; it is the first line of defense in maintaining physiological stability and ensuring patient safety in such cases.
美國護理師在面對急性神經學變化時，擁有較高權限能直接啟動中風或腦出血的緊急反應小組（Stroke Alert/Code Brain），並直接執行標準的神經學評估量表。台灣護理師通常需先執行初步評估並回報主治醫師，由醫師評估後再下達檢查醫囑，較少由護理師主導檢查流程的啟動。