一位 45 歲有高血壓病史的病人主訴突發性劇烈頭痛及視力模糊，測得血壓為 210/130 mmHg。護理師應優先採取的行動為何？
A 45-year-old client with a history of hypertension reports a sudden onset of severe headache and blurred vision. The blood pressure is 210/130 mmHg. Which action is the priority?
- APlace the client in a supine position讓病人採仰臥姿勢
- BPerform a comprehensive neurological assessment進行全面的神經系統評估
- CElevate the head of the bed to 30-45 degrees✓ 正解將床頭抬高30-45度
- DAdminister an oral antihypertensive medication給予口服降壓藥物
此個案呈現高血壓急症（Hypertensive Emergency）症狀，優先目標為減緩腦部壓力並監控末梢灌流。抬高床頭可減少顱內靜脈鬱血，有助於降低顱內壓。平躺會加重腦部血液充盈，口服藥物起效太慢，神經評估應在穩定姿勢後進行，保護腦部灌流是當務之急。
This patient presents with symptoms of a hypertensive emergency. The priority goal is to reduce cerebral pressure and monitor peripheral perfusion. Elevating the head of the bed reduces intracranial venous congestion and helps lower intracranial pressure. Lying flat would aggravate cerebral blood pooling, oral medications take effect too slowly, and neurological assessment should follow stabilization in a proper position. Protecting cerebral perfusion is the immediate priority.
美方醫療體系對高血壓急症有嚴格的 ICU 入住 protocol，台灣則視是否有急性標的器官受損而定，但兩者對床頭角度的護理原則一致。