一名 45 歲高血壓病史病人出現突發性劇烈頭痛及視力模糊，血壓 210/130 mmHg。護理師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. Blood pressure is 210/130 mmHg. Which action is the priority for the nurse?
- AEstablish intravenous access for emergency medication✓ 正解建立靜脈通路以給予緊急藥物
- BAdminister an oral antihypertensive medication給予口服降壓藥物
- CObtain an immediate neurological assessment立即進行神經學評估
- DPlace the client in a high-Fowler’s position將病人置於高福勒氏體位
此為高血壓急症（Hypertensive Emergency），目標是防止終末器官受損。護理師需建立靜脈通路以便給予靜脈注射降壓藥（如 Nitroprusside），這是控制急性血壓飆升的關鍵步驟。高 Fowler’s 位有助緩解呼吸困難但非首要，口服藥物起效太慢，神經評估是重要護理程序但給藥優先。
This is a hypertensive emergency, and the goal is to prevent end-organ damage. The nurse must establish intravenous access to allow administration of IV antihypertensive agents (e.g., nitroprusside), which is the critical step in controlling the acute blood pressure surge. High Fowler's position helps relieve dyspnea but is not the priority; oral medications act too slowly; and neurologic assessment is an important nursing process, but administration of medication takes precedence.
美台臨床對於高血壓急症皆強調速效給藥，但台灣在急診給藥流程常需醫師先確認病歷，美國則多有既定 protocol 可執行。