— 生理適應 · HARD · MCQ —
一名 55 歲高血壓病史病患自述突然發生極度劇烈的「雷擊樣」頭痛。護理師優先採取哪項措施？
A 55-year-old client with a history of hypertension reports a sudden, severe "thunderclap" headache. Which nursing action is the priority?
- AAdminister an analgesic medication as per PRN orders依備用医嘱給予止痛藥物
- BEncourage the client to rest in a dark, quiet room鼓勵病人在黑暗安靜的房間休息
- CPerform a manual blood pressure check進行手動血壓測量
- DPerform a neurological assessment using the Glasgow Coma Scale✓ 正解使用格拉斯哥昏迷量表進行神經學評估
— Explanation · 中文詳解 —
此臨床表現高度懷疑為蛛網膜下腔出血（SAH）。優先進行神經學評估（GCS）能建立基線數據，以便後續判斷病情是否惡化。雷擊樣頭痛屬於危急狀況，需立即通知醫師進行腦部電腦斷層掃描。給止痛藥會掩蓋症狀，靜臥休息對動脈瘤破裂無助，血壓監測重要但不如神經學評估能反映腦部灌流狀態。
A sudden, severe "thunderclap" headache in a hypertensive client suggests a subarachnoid hemorrhage, making neurological assessment the priority. Using the Glasgow Coma Scale establishes a baseline to monitor for deterioration, whereas administering analgesics may mask critical symptoms and delay diagnosis.
✦ 台美臨床差異
美台臨床對於急性顱內壓增高症狀的處置流程一致，皆需先進行神經學評估與神經外科會診。