— 生理適應 · MEDIUM · MCQ —
一名 55 歲高血壓病史病患入院，血壓 180/110 mmHg。下列哪項評估發現最令護理師擔憂？
A 55-year-old client with a history of hypertension is admitted with a blood pressure of 180/110 mmHg. Which assessment finding is most concerning to the nurse?
- AReport of a severe frontal headache主劇烈的前額頭痛
- BDizziness upon standing站立時頭暈
- CBlurry vision and confusion✓ 正解視力模糊與意識混亂
- DBounding radial pulse橈動脈搏動強勁
— Explanation · 中文詳解 —
高血壓急症時，若出現視力模糊與意識混亂，代表已發生腦部受損或高血壓腦病變，屬於末端器官受損的徵兆，優先程度高於單純頭痛。頭痛雖常見，但意識層級改變直接威脅病人安全與神經功能，需立即處理以防不可逆損害。
Blurry vision and confusion indicate end-organ damage, specifically hypertensive encephalopathy, which represents a medical emergency requiring immediate intervention to prevent irreversible neurological injury. While headaches and dizziness are common in hypertension, altered mental status signals critical brain involvement.
✦ 台美臨床差異
美國護理師常依據 Protocol 立即給予降壓藥，台灣通常需確認醫囑並進行嚴密的意識評估記錄。