— 生理適應 · HARD · MCQ —
一位 55 歲高血壓病史病患主訴突然發生如雷擊般的頭痛，優先評估項目為何？
A 55-year-old client with a history of hypertension reports a sudden, severe "thunderclap" headache. Which assessment is the priority?
- APupillary light reflex瞳孔對光反射
- BLevel of consciousness and neurological status✓ 正解意識層次與神經學狀況
- COxygen saturation血氧飽和度
- DBlood pressure and pulse血壓與脈搏
— Explanation · 中文詳解 —
雷擊般頭痛常暗示蜘蛛膜下腔出血（SAH），這屬於神經系統急症。優先評估意識狀態（GCS）與神經學變化，以監測顱內壓升高及出血擴張進展。BP 與瞳孔反射固然重要，但意識改變往往是腦灌注與神經功能受損的最早期警訊。
A sudden "thunderclap" headache suggests a subarachnoid hemorrhage, a neurological emergency where monitoring the level of consciousness is the priority to detect early signs of increased intracranial pressure. While blood pressure and pupillary responses are important, changes in neurological status are the most sensitive indicators of brain perfusion and deterioration.
✦ 台美臨床差異
美國護理師常執行 NIHSS 評估；台灣臨床則依賴醫師執行神經學檢查，護理師輔助觀察。