一位 55 歲有高血壓病史的病人主訴突發嚴重頭痛及視力模糊，血壓 210/120 mmHg。護理師應優先執行哪項措施？
A 55-year-old client with a history of hypertension reports a sudden, severe headache and blurred vision. The nurse notes a blood pressure of 210/120 mmHg. Which action should the nurse perform first?
- AAdminister an oral antihypertensive medication給予口服降血壓藥物
- BAssess the client's neurological status✓ 正解評估病人的神經狀態
- CPerform a blood glucose check進行血糖檢測
- DElevate the head of the bed to 30 degrees將床頭抬高30度
高血壓急症（hypertensive emergency, BP ≥180/120 + 末端器官損害徵象）的優先動作為立即評估末端器官損害並啟動降壓措施。本題病人 BP 210/120 + 嚴重頭痛 + 視力模糊提示腦血管事件可能（如顱內出血、高血壓性腦病），現有選項中 C「神經學評估」為合理優先：評估意識、瞳孔、肢體力以引導後續處置（IV 降壓藥、影像）。其他選項：D 抬高床頭 30 度為支持性處置；B 口服降壓藥對急症太慢；D 血糖檢查雖有助排除低血糖但非主要鑑別方向。
The client presents with signs of a hypertensive emergency, indicated by severely elevated blood pressure and symptoms suggesting end-organ damage such as a severe headache and blurred vision. The priority nursing action is to assess the neurological status to detect specific deficits like changes in level of consciousness or motor function. This assessment guides immediate interventions, such as administering IV antihypertensives, to prevent further complications like stroke.
美國護理師在嚴格醫囑下可調整體位；台灣醫療環境對血壓危象有標準操作流程，護理師需立即回報並準備靜脈點滴。