— 生理適應 · HARD · MCQ —
一位 45 歲高血壓病史病人主訴突發嚴重頭痛及視力模糊，血壓 210/130 mmHg。優先採取的護理措施為何？
A 45-year-old client with a history of hypertension reports a sudden onset of severe headache and blurred vision. The BP is 210/130 mmHg. Which action is the priority?
- APlace the client in a supine position讓客戶採取仰臥姿勢
- BInitiate continuous blood pressure monitoring✓ 正解開始連續血壓監測
- CObtain a bedside blood glucose level測量床邊血糖值
- DAdminister an oral antihypertensive medication給予口服降血壓藥物
— Explanation · 中文詳解 —
此個案呈現高血壓急症（Hypertensive Emergency），目標為防止靶器官受損。持續監測血壓是評估降壓治療效果的首要任務。口服藥物起效太慢，且體位應維持頭高位以降低顱內壓。監測生理參數是後續給藥與評估的重要基礎。
This client is experiencing a hypertensive emergency, requiring immediate continuous blood pressure monitoring to prevent target organ damage. Maintaining the head of the bed elevated helps reduce intracranial pressure, while oral medications are inappropriate due to their slow onset of action.
✦ 台美臨床差異
美台臨床對於高血壓急症皆強調靜脈給藥，但美國急診護理師常有更寬的依據 protocol 啟動動脈導管監測之授權。