— 生理適應 · HARD · MCQ —
一位 45 歲高血壓病史病人主訴突發劇烈頭痛、視力模糊，血壓 210/130 mmHg。護理師應採取何項優先行動？
A 45-year-old client with a history of hypertension reports a sudden, severe headache, blurred vision, and a blood pressure of 210/130 mmHg. Which action is the priority for the nurse?
- APerform a neurological assessment進行神經學評估
- BPlace the client in a high-Fowler's position✓ 正解將病人置於高福勒氏臥位
- CAdminister an oral antihypertensive medication給予口服抗高血壓藥物
- DObtain an EKG進行心電圖檢查
— Explanation · 中文詳解 —
此為高血壓急症（Hypertensive Emergency），首重減緩顱內壓力與降低心臟負載。半坐臥姿可減少腦部充血。C 選項口服藥起效太慢，通常需靜脈給藥；C 為評估，需在處置後進行；D 非最緊急檢查項目。
In a hypertensive emergency, placing the client in a high-Fowler's position is the priority to decrease intracranial pressure and reduce cardiac workload. Oral medications act too slowly, and other assessments or interventions follow this immediate stabilization step.
✦ 台美臨床差異
美國護理師常依 Protocol 直接給予靜脈降壓藥；台灣則嚴格要求醫師評估後開立給藥，護理師監測生命徵象。