一位 55 歲高血壓病史病患主訴突發嚴重頭痛、視力模糊，血壓 210/130 mmHg。護理師優先採取的行動為何？
A 55-year-old client with a history of hypertension reports a sudden, severe headache, blurred vision, and a blood pressure of 210/130 mmHg. Which action is the priority?
- AAssess for signs of neurological deficits✓ 正解評估神經學缺損跡象
- BAdminister an oral antihypertensive medication as prescribed依醫囑給予口服抗高血壓藥物
- CPlace the client in a low-Fowler's position將個案置於低福勒氏氏體位
- DObtain an immediate electrocardiogram立即進行心電圖檢查
此個案呈現高血壓急症（Hypertensive Emergency）徵象，伴隨標的器官損傷。優先任務為評估神經學狀況，以排除中風或顱內出血等急性併發症。口服降壓藥通常效力過慢，且需在嚴密監控下使用靜脈滴注藥物降壓，避免血壓下降過快導致腦灌流不足。
The client is experiencing a hypertensive emergency with potential target organ damage, necessitating an immediate neurological assessment to rule out stroke or intracranial hemorrhage. Rapid blood pressure reduction is required but must be carefully monitored to avoid compromising cerebral perfusion. Oral medications act too slowly for this acute situation, and while positioning and ECGs have roles, neurological status is the primary concern.
美國處理高血壓急症偏向 ICU 內靜脈給藥監測，台灣亦然，但部分醫院在 ER 有更嚴格的降壓速度規範。