一位 55 歲高血壓病史病人主訴劇烈頭痛及視力模糊，血壓為 220/130 mmHg。護理師應優先採取何項措施？
A 55-year-old client with a history of hypertension reports severe headache and blurred vision. The blood pressure is 220/130 mmHg. Which action is the priority for the nurse?
- AElevate the head of the bed to 45 degrees✓ 正解將床頭抬高至 45 度
- BPerform a comprehensive neurological assessment執行全面的神經學評估
- CAdminister the prescribed oral antihypertensive medication給予處方口服降血壓藥物
- DPrepare for the administration of intravenous vasodilator therapy準備給予靜脈血管擴張劑治療
此個案呈現高血壓急症（Hypertensive Emergency）的特徵，包括嚴重血壓飆升伴隨末梢器官受損風險（頭痛、視力模糊代表腦血管壓力極大）。首先，將床頭抬高 45 度是安全的第一步，這有助於利用重力減輕腦部靜脈充血，降低顱內壓。接著，護理師需評估生命徵象與意識狀態，建立靜脈通路，準備如 Nitroprusside 或 Labetalol 的靜脈注射藥物，以受控的方式降低血壓。不能口服降血壓藥是因為吸收太慢且無法精準控制降壓幅度。神經評估固然重要，但在處置急性高血壓危象時，物理性降低頭部壓力是呼吸循環維持後的優先動作，以防止腦出血。臨床思維應放在『減壓』與『精準給藥』之間的平衡，而非單一的檢查動作。
This case demonstrates features of a hypertensive emergency, including a severe surge in blood pressure with risk of end-organ damage (the headache and blurred vision reflect markedly elevated cerebrovascular pressure). First, elevating the head of the bed to 45 degrees is a safe initial step, as it uses gravity to reduce cerebral venous congestion and lower intracranial pressure. Next, the nurse should assess vital signs and level of consciousness, establish intravenous access, and prepare IV agents such as nitroprusside or labetalol to lower blood pressure in a controlled manner. Oral antihypertensives are inappropriate because they are absorbed too slowly and cannot be titrated precisely. Although neurologic assessment is important, in the management of an acute hypertensive crisis, physically reducing pressure at the head is the priority once airway, breathing, and circulation are addressed, in order to prevent intracerebral hemorrhage. Clinical reasoning should focus on balancing decompression with precise pharmacologic intervention, not on a single diagnostic action.
美國醫院針對高血壓急症常有預設的護理師執行常規（Standing Orders）以快速給予 IV 藥物，台灣則較嚴謹，必須確認醫師開立醫囑後才能給予抗高血壓藥物，護理師的角色多側重於監測與通報。