一位 55 歲高血壓病史病人主訴頭痛、視力模糊與噁心，血壓 220/130 mmHg。護理師應優先採取何項措施？
A 55-year-old client with a history of hypertension reports severe headache, blurred vision, and nausea. Blood pressure is 220/130 mmHg. Which action is the priority?
- AAdminister IV antihypertensive medication as prescribed✓ 正解依醫囑給予靜脈注射抗高血壓藥物
- BMaintain a quiet, darkened room維持安靜、昏暗的房間
- CObtain a complete neurologic assessment進行完整的神經學評估
- DAdminister sublingual nitroglycerin給予舌下硝酸甘油
此為高血壓急症（Hypertensive Emergency），目標為透過靜脈輸注降血壓藥物（如 Nitroprusside 或 Labetalol）在數小時內緩慢降低平均動脈壓，以防止終端器官受損。口服或舌下藥物作用不穩定且難以精確控制。神經評估固然重要，但在處理威脅性極高的血壓數值時，給予緊急藥物控制血壓是穩定灌流的關鍵。
This client is experiencing a hypertensive emergency, requiring immediate administration of intravenous antihypertensive medication to rapidly yet controlledly lower blood pressure and prevent end-organ damage. IV titration offers precise control over the rate of blood pressure reduction, which is superior to the unpredictable absorption of sublingual or oral medications. While assessment is important, stabilizing the hemodynamic crisis takes priority.
美國 ICU 護理師依醫囑滴注降壓藥並自行調整；台灣臨床常規中，調整藥物速度需較嚴謹的醫囑規範。