— 生理適應 · HARD · MCQ —
一位 45 歲有高血壓病史的病人主訴突發嚴重頭痛、視力模糊及噁心，血壓 210/130 mmHg。護理師的首要介入為何？
A 45-year-old client with a history of hypertension reports a sudden, severe headache, blurred vision, and nausea. The blood pressure is 210/130 mmHg. What is the nurse's priority intervention?
- AAdminister an oral antihypertensive medication給予口服降血壓藥物
- BAssess the client's neurologic status and level of consciousness✓ 正解評估病人的神經學狀態與意識層次
- CPlace the client in a high-Fowler’s position將病人置於高福勒氏臥位
- DPerform a bladder scan to assess for urinary retention進行膀胱掃描以評估是否有尿液滯留
— Explanation · 中文詳解 —
此個案呈現高血壓急症（Hypertensive Emergency），目標是防止標的器官損傷。首要任務為進行神經學評估，確定有無腦部病變（如中風或腦出血）的跡象。降血壓藥物通常需靜脈注射，口腔給藥效果太慢，且需謹慎控制降壓速度以免造成腦部灌流不足。
The client is experiencing a hypertensive emergency, requiring immediate assessment of neurologic status to establish a baseline for potential organ damage such as stroke or hemorrhage. Oral medications are inappropriate due to slow absorption, and while positioning may help, assessing for neurologic impairment is the priority intervention.
✦ 台美臨床差異
美國醫護常見高血壓急症流程，護理師需快速完成神經學檢查；台灣臨床常規亦然，但強調需儘速會診神經內科。