— 生理適應 · MEDIUM · MCQ —
一名 55 歲高血壓病史病人入院時血壓 180/110 mmHg。護理師應優先評估下列何種臨床徵象？
A 55-year-old client with a history of hypertension is admitted with a blood pressure of 180/110 mmHg. Which assessment finding is the priority for the nurse to evaluate?
- AHeart rate of 88 beats per minute心率每分鐘 88 次
- BSudden onset of confusion and severe headache✓ 正解突然出現的混亂與嚴重頭痛
- CBilateral pedal edema雙側足部水腫
- DReports of mild dizziness upon standing站立時報告輕微頭暈
— Explanation · 中文詳解 —
高血壓急症（Hypertensive crisis）需優先識別標的器官損害徵象。意識混亂與劇烈頭痛暗示腦灌流壓力過高或腦水腫，這是神經系統受損的危險訊號，若未及時處理恐引發腦中風，因此評估神經學狀態為優先處置。
In a hypertensive crisis, the priority is identifying signs of end-organ damage, particularly affecting the brain. Sudden confusion and severe headache indicate potential cerebral edema or impaired perfusion, which are critical neurological deficits requiring immediate intervention to prevent stroke.
✦ 台美臨床差異
美方對於高血壓急症的 ICU 收治標準較嚴格，台灣臨床則常先於一般病房進行藥物控制。