一位 55 歲有高血壓病史的病人主訴突發性、一生中最劇烈的頭痛。護理師應優先採取哪項措施？
A 55-year-old client with a history of hypertension reports a sudden onset of a severe headache described as the 'worst headache of my life.' Which action is the priority for the nurse?
- AEncourage the client to rest in a dark, quiet room鼓勵病人在黑暗安靜的房間休息
- BAdminister an analgesic as ordered依醫囑給予止痛藥
- CAssess the client's pupillary response and level of consciousness✓ 正解評估病人的瞳孔反應與意識程度
- DPerform a comprehensive neurological exam執行全面的神經學檢查
此臨床表現高度懷疑為腦動脈瘤破裂導致的蜘蛛網膜下腔出血（SAH）。優先評估神經學狀態可判斷是否有腦壓過高或腦疝跡象。給予止痛藥會掩蓋臨床症狀；臥床休息會延誤搶救；完整神經學檢查應在快速初步評估後執行。
This clinical presentation raises high suspicion for subarachnoid hemorrhage (SAH) due to a ruptured cerebral aneurysm. Prioritizing neurologic assessment can determine whether there are signs of increased intracranial pressure or brain herniation. Administering analgesics masks clinical symptoms; bed rest delays rescue; and a comprehensive neurologic exam should be performed after the focused initial assessment.
美國護理師常受過 NIHSS 評估訓練並能主動啟動 Code Stroke；台灣護理師多等待醫師指令後進行檢查。