— 生理適應 · MEDIUM · MCQ —
一位 45 歲有高血壓病史的病人出現突發性劇烈頭痛、視力模糊及意識混亂，血壓 210/130 mmHg。下列何者為優先護理處置？
A 45-year-old client with a history of hypertension reports a sudden onset of severe headache, blurred vision, and confusion. Blood pressure is 210/130 mmHg. Which action is the priority?
- APlace the client in a high-Fowler's position將病人置於高福勒氏臥位
- BObtain a complete neurologic assessment進行完整的神經學評估
- CAdminister IV antihypertensives as ordered✓ 正解依醫囑給予靜脈注射降血壓藥物
- DPerform a fingerstick blood glucose test執行指尖血糖測試
— Explanation · 中文詳解 —
此為高血壓急症（Hypertensive Emergency），目標是在 1 小時內將平均動脈壓降低不超過 25%，以預防器官損傷。靜脈給予降壓藥物是穩定病情的關鍵。若處理不及，易導致腦出血或急性心衰竭。
The client is experiencing a hypertensive emergency, characterized by severely elevated blood pressure with signs of end-organ damage. The priority action is to administer IV antihypertensives as ordered to rapidly lower blood pressure and prevent further complications such as stroke or heart failure.
✦ 台美臨床差異
美國 ICU/ER 護理師依醫囑調控滴注泵；台灣護理師需醫師確認頻率後方可調整。