一位 55 歲高血壓病人出現突發性劇烈頭痛、視力模糊及噁心，血壓 210/120 mmHg。護理師應優先採取何種措施？
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 is the priority?
- AAdminister the prescribed oral antihypertensive medication給予處方之口服降壓藥物
- BPlace the client in a semi-Fowler's position to reduce intracranial pressure將病人置於半坐臥位以降低顱內壓
- CObtain an EKG to check for myocardial strain進行心電圖檢查以評估心肌應變
- DEstablish intravenous access for rapid-acting antihypertensive agents✓ 正解建立靜脈通路以給予快速作用之降壓劑
此個案呈現高血壓急症（Hypertensive Emergency），伴隨標靶器官受損徵兆（頭痛、視力模糊、噁心）。目標為迅速且受控地降低血壓以防止進一步器官損壞，IV 靜脈給藥是臨床首選。口服藥物起效太慢；擺位僅為輔助；EKG 是必要的評估但非首要搶救行動。
The client is experiencing a hypertensive emergency, indicated by severely elevated blood pressure and signs of target organ damage such as headache and blurred vision. Immediate intravenous access is the priority to administer rapid-acting antihypertensive agents for controlled blood pressure reduction. Oral medications act too slowly, and while positioning and diagnostic tests like EKGs are useful, they do not address the immediate life-threatening physiological instability.
美台臨床皆視高血壓急症為危急情況。美國護理師常依院內 Protocol 執行靜脈滴注；台灣多在醫師監督下執行。