— 生理適應 · MEDIUM · MCQ —
一名 55 歲高血壓病史個案入院時測得血壓為 180/110 mmHg。下列哪項評估發現需要最立即的護理措施？
A 55-year-old client with a history of hypertension is admitted with a blood pressure of 180/110 mmHg. Which assessment finding requires the most immediate nursing intervention?
- APatient report of chest pain✓ 正解病人主訴胸痛
- BPatient report of blurred vision病人主訴視力模糊
- CPatient report of a throbbing headache病人主訴搏動性頭痛
- DPatient report of numbness in the feet病人主訴腳部麻木
— Explanation · 中文詳解 —
高血壓急症（Hypertensive Emergency）的定義在於血壓升高伴隨「末端器官受損」（Target Organ Damage）。胸痛（Chest pain）暗示可能併發心肌梗塞或主動脈剝離，這是直接威脅生命的急症（ABC 原則：循環系統危機）。頭痛與視力模糊雖為高血壓表現，但威脅程度不及胸痛。
Hypertensive emergency is defined by severe blood pressure elevation accompanied by target organ damage. Chest pain suggests acute coronary syndrome or aortic dissection, which are immediate life-threatening circulatory crises requiring urgent intervention.