— 生理適應 · MEDIUM · MCQ —
一位 55 歲高血壓病史病人主訴突發嚴重頭痛、視力模糊與意識混亂，血壓 210/130 mmHg。護理師應優先採取什麼行動？
A 55-year-old client with a history of hypertension reports a sudden, severe headache, blurred vision, and confusion. Blood pressure is 210/130 mmHg. Which action is the priority?
- ALower the head of the bed to ensure cerebral perfusion降低床頭高度以確保腦部灌流
- BPrepare for immediate transfer to the intensive care unit✓ 正解準備立即轉入加護病房
- CObtain a neurological assessment using the Glasgow Coma Scale使用格拉斯哥昏迷量表進行神經評估
- DAdminister an oral antihypertensive medication給予口服抗高血壓藥物
— Explanation · 中文詳解 —
此個案呈現高血壓急症（Hypertensive Emergency），目標是在監測下將血壓逐漸控制以防止器官損傷。進入加護病房是為了進行嚴密監測並給予靜脈注射降壓藥，此為處理急性高血壓危機的標準處置。
This client is experiencing a hypertensive emergency characterized by severely elevated blood pressure and signs of end-organ damage such as confusion and visual changes. The priority action is to prepare for immediate transfer to the intensive care unit for continuous monitoring and titration of intravenous antihypertensive medications.
✦ 台美臨床差異
美國醫院針對高血壓急症有嚴格的 ICU 收治準則；台灣則視醫院床位及專科別而定，有時在急診觀察區即可進行。