一位 55 歲高血壓病史病患主訴突發嚴重頭痛、視力模糊與噁心，血壓 210/120 mmHg。護理師應優先採取哪項行動？
A 55-year-old client with a history of hypertension reports a sudden, severe headache, blurred vision, and nausea. The blood pressure is 210/120 mmHg. Which action should the nurse take first?
- AElevate the head of the bed to 30-45 degrees✓ 正解將床頭抬高 30-45 度
- BPerform a neurological assessment進行神經學評估
- CAdminister an antihypertensive medication as ordered依醫囑給予抗高血壓藥物
- DObtain an EKG取得心電圖
此為高血壓急症（Hypertensive Emergency）。優先採取降低顱內壓的措施（抬高床頭）有助於減緩腦水腫與頭痛，並確保氣道通暢，隨後才進行藥物治療與神經學評估。迅速降低血壓雖重要，但需預防腦灌流不足，調整體位為最快且安全的護理作為。
This is a hypertensive emergency. Prioritizing measures to lower intracranial pressure (elevating the head of the bed) helps ease cerebral edema and headache and ensures airway patency, after which pharmacologic therapy and neurologic assessment can follow. Although rapid blood pressure reduction is important, cerebral hypoperfusion must be avoided; repositioning is the quickest and safest immediate nursing action.
美國護理師常依急診室標準護理常規抬高床頭，台灣臨床在處理高血壓急症時亦同，但藥物給予流程極度依賴醫師指令。