一位 45 歲高血壓病史病人主訴突發嚴重頭痛、視力模糊及噁心。血壓 210/130 mmHg。護理師優先採取的行動為何？
A 45-year-old client with a history of hypertension reports a sudden, severe headache, blurred vision, and nausea. The client's blood pressure is 210/130 mmHg. Which action is the priority for the nurse?
- AAdminister the client's scheduled oral antihypertensive medication給予案主預定之口服降血壓藥物
- BPerform a neurological assessment to establish a baseline進行神經學評估以建立基線
- CPlace the client in a high-Fowler’s position and notify the provider immediately✓ 正解將案主置於高福勒氏體位並立即通知醫師
- DObtain a bedside blood glucose level to rule out hypoglycemia測量床邊血糖以排除低血糖
此為高血壓危象（Hypertensive Crisis），目標是降低心臟負荷並立即通知醫師進行靜脈給藥。採高坐姿有助於緩解呼吸困難與減輕顱內壓力。口服藥物吸收太慢，且需優先執行穩定生命徵象之措施，而非僅僅是初步評估。
The client is experiencing a hypertensive crisis, indicated by severely elevated blood pressure and end-organ damage symptoms like headache and blurred vision. Placing the client in a high-Fowler’s position helps reduce intracranial pressure and ease breathing while the provider is notified for immediate IV antihypertensive therapy. Oral medications act too slowly for this emergency.
美國護理師在 Protocol 下可直接啟動緊急處置流程；台灣則多需先由住院醫師確認並開立醫囑後方可執行。