一位 55 歲高血壓病史病人主訴突發劇烈頭痛及視力模糊，血壓 210/130 mmHg。護理師應優先採取何種行動？
A 55-year-old client with a history of hypertension reports a sudden, severe headache and blurred vision. The blood pressure is 210/130 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
- BObtain a bedside glucose check進行床邊血糖檢測
- CAdminister an oral antihypertensive medication as ordered依醫囑給予口服降血壓藥物
- DPrepare for immediate administration of IV vasodilators準備立即給藥靜脈血管擴張劑
面對高血壓急症（Hypertensive Emergency），首要目標是降低顱內壓力並保護器官灌流。將床頭抬高 45 度是降低顱內壓的非侵入性首要動作，能有效改善腦部血液回流並減輕腦水腫引發的頭痛症狀。雖然藥物治療是核心，但在給予降壓藥物前，必須先建立穩定的擺位以降低急性神經學風險。此病人呈現高血壓危象，若血壓下降過快過猛，反而會造成腦組織缺血，因此必須監測藥物反應。其他選項中，口服藥物起效太慢，不符合高血壓危象處置需求；IV 藥物需配合嚴密監測；血糖檢測雖然重要，但優先級遠低於腦部灌流與壓力調控。
When confronting a hypertensive emergency, the primary goal is to lower intracranial pressure and protect organ perfusion. Elevating the head of the bed to 45 degrees is the first non-invasive action to reduce intracranial pressure, effectively improving cerebral venous return and relieving headache caused by cerebral edema. Although pharmacologic therapy is central, a stable position must be established before administering antihypertensive medications in order to reduce acute neurologic risk. This client presents with a hypertensive crisis; if blood pressure drops too rapidly or too sharply, cerebral ischemia may result, so the response to medication must be carefully monitored. Among the other options, oral medications act too slowly to meet the needs of a hypertensive crisis; IV medications require strict monitoring; and although glucose testing is important, it is far lower in priority than cerebral perfusion and pressure control.
美國醫院常見針對高血壓危象有標準護理程序（Protocol），護理師可預先依據醫囑執行初步生命徵象監控與擺位；台灣部分醫院依據病人安全規範，給予強力降壓劑前需由醫師現場評估並確認給藥滴速。