一位 55 歲高血壓病史病患主訴突發嚴重頭痛、視力模糊及噁心，血壓 210/130 mmHg。護理師應優先採取何項措施？
A 55-year-old client with a history of hypertension reports a sudden, severe headache, blurred vision, and nausea. The blood pressure is 210/130 mmHg. Which action is the priority for the nurse?
- APlace the client in a high-Fowler's position✓ 正解將病人置於高福勒氏臥位
- BPrepare the client for an immediate CT scan準備病人立即進行電腦斷層掃描
- CAdminister an oral antihypertensive medication給予口服降壓藥物
- DObtain a baseline neurological assessment取得基線神經學評估
此為高血壓急症（Hypertensive Emergency）。優先採取半坐臥姿（High-Fowler's）可減輕頭部充血及緩解呼吸壓力，幫助降低顱內壓。C 項口服藥降壓太慢，通常需靜脈給藥；D、B 項雖為重要護理及醫療步驟，但在呼吸與循環穩定後才進行。
The client is experiencing a hypertensive emergency with signs of end-organ damage, such as headache and blurred vision. Placing the client in a high-Fowler's position is the priority nursing action as it reduces venous return and helps decrease intracranial pressure. While diagnostic tests and IV antihypertensives are necessary, stabilizing the client's position supports respiratory and circulatory function first.
美國護理師常依急診 protocol 給予 IV 降壓劑，台灣多需醫師處方下執行。