— 生理適應 · MEDIUM · MCQ —
一名 55 歲高血壓病史病患入院，血壓 185/110 mmHg。下列哪項生理評估發現需最優先介入？
A 55-year-old client with a history of hypertension is admitted with a blood pressure of 185/110 mmHg. Which physiological assessment finding requires the most urgent intervention?
- ABilateral pitting edema雙側凹陷性水腫
- BHeart rate of 88 beats per minute心率每分鐘 88 次
- CReports of mild headache主訴輕微頭痛
- DSudden onset of confusion and blurred vision✓ 正解突然出現意識混亂與視力模糊
— Explanation · 中文詳解 —
高血壓急症（Hypertensive Emergency）的特徵是血壓極高伴隨器官損傷風險。混亂與視力模糊顯示腦部灌流異常，可能演變為高血壓腦病變，屬於神經系統危急狀況，必須立即給予降壓藥物，以防不可逆的腦損傷。
Sudden confusion and blurred vision are signs of hypertensive encephalopathy, indicating acute brain injury due to severely elevated blood pressure. This neurological compromise represents a medical emergency requiring immediate intervention to prevent irreversible damage.
✦ 台美臨床差異
美國護理師常依據 ICU 指引執行降壓滴注，台灣則多需嚴格遵循醫師開立的藥物滴定速度。