— 生理適應 · HARD · MCQ —
一名 45 歲高血壓病患突發嚴重頭痛、視力模糊及意識混亂。血壓為 210/130 mmHg。護理師應優先採取的行動為何？
A 45-year-old client with a history of hypertension reports a sudden onset of severe headache, blurred vision, and confusion. Blood pressure is 210/130 mmHg. Which action is the priority for the nurse?
- AMonitor the client's vital signs every 15 minutes每 15 分鐘監測病患的生命徵象
- BEstablish intravenous access and prepare for IV antihypertensive therapy✓ 正解建立靜脈通路並準備靜脈注射抗高血壓藥物
- CAdminister an oral antihypertensive medication as ordered依醫回給予口服抗高血壓藥物
- DPlace the client in a high-Fowler's position將病患置於半坐臥位（High-Fowler's position）
— Explanation · 中文詳解 —
此個案呈現高血壓急症（Hypertensive Emergency）徵象，存在腦損傷風險，需立即經由靜脈給藥以快速降低血壓。口服藥物起效太慢，首要任務是建立靜脈通路以便給藥。高半坐臥位可緩解腦壓，但非最優先。生命徵象監測雖重要，但需先建立治療管道。
The client is exhibiting signs of a hypertensive emergency with potential end-organ damage, requiring immediate blood pressure reduction via intravenous antihypertensive agents. Establishing IV access is the priority to allow for rapid administration of these medications, as oral agents act too slowly for this acute situation.
✦ 台美臨床差異
美國常規使用 Labetalol 或 Nicardipine 靜脈滴注；台灣臨床也多採用類似 protocol，但藥物選擇常受限於醫院 formulary。