— 生理適應 · MEDIUM · MCQ —
一位 55 歲高血壓病史病人入院，血壓為 185/110 mmHg。下列哪項護理措施為優先？
A 55-year-old client with a history of hypertension is admitted with a blood pressure of 185/110 mmHg. Which nursing intervention is the priority?
- AAdminister the prescribed oral antihypertensive medication給予處方之口服抗高血壓藥物
- BElevate the head of the bed to 45 degrees將床頭抬高至 45 度
- CAssess the client for neurological deficits or visual changes✓ 正解評估病人是否有神經學缺失或視力改變
- DObtain an immediate electrocardiogram立即取得心電圖
— Explanation · 中文詳解 —
高血壓急症（Hypertensive emergency）定義為血壓極高（通常 >180/120 mmHg）且伴隨急性「器官損傷（Target organ damage）」。護理師的首要任務是評估是否有腦部、心臟或腎臟受損的徵兆。其中，神經學症狀（如意識改變、視力模糊、劇烈頭痛）暗示可能發生高血壓腦病變（Hypertensive encephalopathy）或中風，這是最致命的併發症，需優先評估以決定後續救治策略。
Hypertensive emergency involves severely elevated blood pressure with acute target organ damage, such as hypertensive encephalopathy or stroke. The priority nursing intervention is assessing for neurological deficits or visual changes to determine the urgency of the situation.