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正確答案
- D準備立即給藥靜脈血管擴張劑
血壓 210/130 mmHg 合併突發劇烈頭痛與視力模糊，代表血壓升高已造成急性標的器官損傷（高血壓腦病變的典型表現），屬高血壓急症（hypertensive emergency）。依 2025 AHA/ACC 指引，這類病人需收治加護單位，在密切血壓監測下以靜脈降壓藥受控降壓，因此準備立即給予靜脈血管擴張劑是本題的優先行動（D 為正解）。 必須一併分清楚的對照是：血壓同樣超過 180/120 mmHg 但「沒有」急性器官損傷者，2025 指引已取消 hypertensive urgency 一詞，改稱 severe hypertension，處置為重新啟用或加強口服藥物並密切門診追蹤，不做快速靜脈降壓。本題的頭痛與視力模糊正是把病人歸入急症端的依據。 其他選項：A（抬高床頭 45 度）是擺位與舒適措施，不會降低血壓，也沒有證據支持它是高血壓急症的優先處置。B（床邊血糖檢測）在意識或神經症狀變化時是合理的鑑別診斷步驟，但本題病因已由極高血壓合併典型症狀指明，血糖檢測不能取代立即的降壓準備。C（口服降壓藥）吸收慢且降幅不可控，不符合急症所需的受控降壓。
- A將床頭抬高至45度
抬高床頭能協助頭部靜脈回流，直接且安全地降低顱內壓力，是處理突發神經學症狀合併高血壓時的優先護理措施。
- B進行床邊血糖檢測
血糖值能協助鑑別診斷意識改變，但相較於目前明顯的血壓危象，血糖檢測並非降低顱內壓力之關鍵優先項目。
- C依醫囑給予口服降血壓藥物
高血壓危象需要快速且可滴定的治療，口服藥物在急症中無法確保預期療效，且起效緩慢，延誤治療黃金時間。
- D · 正確答案準備立即給藥靜脈血管擴張劑
靜脈注射血管擴張劑是治療計畫的一環，但必須在醫師評估過血壓下降速度與目標後才能開始，護理師需先進行擺位護理。
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。
English explanation
Option D is correct because a blood pressure of 210/130 mmHg with sudden severe headache and blurred vision indicates acute target-organ injury with typical hypertensive encephalopathy findings, making this a hypertensive emergency. Under 2025 AHA/ACC guidance, the client requires intensive care, close blood pressure monitoring, and controlled reduction with intravenous antihypertensive medication, so immediate preparation for IV vasodilators is the priority. Option A is incorrect because elevating the head of the bed to 45 degrees is a positioning and comfort measure that does not lower blood pressure and is not the priority treatment. Option B is incorrect because a bedside glucose check can assist the differential diagnosis when consciousness or neurological symptoms change, but it cannot replace immediate preparation to lower blood pressure in this presentation. Option C is incorrect because oral antihypertensive medication is absorbed slowly and cannot provide controlled reduction. Severe hypertension above 180/120 mmHg without acute organ injury is managed with oral therapy and close outpatient follow-up, but these symptoms place the client in the emergency category.
最近修訂：2026-05-17