— 生理適應 · MEDIUM · MCQ —
一位 55 歲高血壓病史病患，突發劇烈頭痛，血壓 210/120 mmHg。護理師應優先採取何種措施？
A 55-year-old client with a history of hypertension presents with sudden onset of severe headache and BP 210/120 mmHg. Which action should the nurse prioritize?
- AObtain a neurological assessment✓ 正解進行神經學評估
- BPlace the client in a high-Fowler's position將個案置於高福勒氏臥位
- CAdminister oral antihypertensive medication給予口服降血壓藥物
- DPrepare for rapid blood pressure lowering準備快速降低血壓
— Explanation · 中文詳解 —
高血壓急症時，優先評估神經學狀態以排除腦出血或腦水腫，這是防止惡化的首要任務。給藥需根據醫囑並緩慢執行，避免血壓瞬間過低導致腦灌流不足（Cerebral perfusion pressure 降低）。高頭位對降低顱內壓有幫助，但評估神經狀況對生命徵象監控更為關鍵。
When managing a hypertensive emergency, the nurse must prioritize obtaining a neurological assessment to detect signs of end-organ damage such as stroke or hemorrhage. Rapid blood pressure reduction is generally avoided to prevent cerebral ischemia, and while positioning may help, assessing neurological status is critical for determining appropriate medical interventions.
✦ 台美臨床差異
美國護理師常依據急症處理 Protocol 優先評估與備藥；台灣臨床多依賴醫師開立降壓藥後護理師執行，護理師需警覺不可過快給藥。