一位 55 歲高血壓病史病患主訴突發嚴重頭痛。護理師測得血壓 210/120 mmHg。何項護理措施最為關鍵？
A 55-year-old client with a history of hypertension reports a sudden, severe headache. The nurse measures a blood pressure of 210/120 mmHg. Which nursing action is most critical?
- APerform a neurological assessment including pupil reaction✓ 正解執行包含瞳孔反應的神經學評估
- BAdminister an oral antihypertensive medication immediately立即給予口服抗高血壓藥物
- CObtain an ECG and monitor for cardiac arrhythmias進行心電圖檢查並監測心律不整
- DPlace the client in a high-Fowler’s position讓病人採取半坐臥位（High-Fowler's position）
此為高血壓危象（Hypertensive Crisis），必須優先執行神經學評估（GCS、瞳孔、肢體力氣），因為需立即排除高血壓腦病變或腦出血的可能性。口服降壓藥作用太慢；高半坐臥位對降低腦壓有幫助但非最優先指標；心電圖為次要檢查。確認有無神經損傷是臨床處置的首要目標。
This is a hypertensive crisis, and a neurologic assessment (GCS, pupils, limb strength) must be performed first, because the possibility of hypertensive encephalopathy or intracerebral hemorrhage must be ruled out immediately. Oral antihypertensives act too slowly; the high semi-Fowler's position is helpful for reducing intracranial pressure but is not the highest-priority indicator; the ECG is a secondary investigation. Confirming the presence or absence of neurologic injury is the foremost goal of clinical management.
美國醫護對於高血壓危象多依賴 ICU 規格動脈壓力監測；台灣臨床常見先給予舌下或靜脈降壓藥，兩地對於神經學監測同樣重視。