一名 55 歲高血壓病患出現突發性劇烈頭痛、頸部僵硬及畏光。護理師應優先採取何種行動？
A 55-year-old client with a history of hypertension reports a sudden, severe headache, neck stiffness, and photophobia. What is the priority nursing action?
- APerform a lumbar puncture to rule out meningitis進行腰椎穿刺以排除腦膜炎
- BElevate the head of the bed to 45 degrees將床頭抬高至45度
- CAdminister a PRN analgesic for the headache給予處方備用止痛藥以緩解頭痛
- DPerform a neurological assessment using the Glasgow Coma Scale✓ 正解使用格拉斯哥昏迷量表進行神經學評估
此臨床表現高度懷疑為蜘蛛膜下腔出血（SAH）。優先進行神經學評估（GCS）能提供基準線數據，評估是否有意識改變及 ICP 升高的風險，這是處理顱內病變的首要原則。C 會掩蓋病情，A 是醫囑性診斷而非護理優先處置，B 雖可緩解，但非最急迫。
The sudden onset of a severe headache, neck stiffness, and photophobia suggests a subarachnoid hemorrhage, making immediate neurological assessment the priority. Performing a Glasgow Coma Scale evaluation establishes a baseline to detect changes in intracranial pressure or consciousness. Interventions such as administering analgesics or performing a lumbar puncture are inappropriate before a thorough assessment and medical evaluation.
美國護理師常執行 NIHSS 評估，台灣則依各醫院標準化量表執行，但兩者對神經變化均極度敏感。