— 生理適應 · HARD · MCQ —
一位 45 歲有高血壓病史的個案，主訴突發性劇烈枕部頭痛及視力模糊，血壓 210/130 mmHg。護理師應優先採取何種行動？
A 45-year-old client with a history of hypertension reports a sudden onset of severe occipital headache and blurred vision. The blood pressure is 210/130 mmHg. Which action is the priority?
- AElevate the head of the bed to 45 degrees將床頭抬高至45度
- BPerform a neurological assessment進行神經學評估
- CAdminister an antihypertensive medication as ordered✓ 正解依醫囑給予抗高血壓藥物
- DObtain an ECG取得心電圖
— Explanation · 中文詳解 —
此個案呈現高血壓急症（Hypertensive Crisis），目標在於預防終端器官損傷。優先給予降壓藥物以降低平均動脈壓，這是穩定生理適應的關鍵。A 選項可減輕顱內壓但非最直接的藥物治療，D 與 B 雖然重要，但在給藥控制血壓前應優先處理致命的血壓過高。
This client is experiencing a hypertensive crisis, which requires rapid blood pressure reduction to prevent end-organ damage such as stroke or renal failure. Administering prescribed antihypertensive medication is the priority intervention to stabilize the client's physiological status.
✦ 台美臨床差異
美國醫院常見針對 Hypertensive Crisis 的緊急給藥 Protocol，台灣則多由醫師評估後親自開立處方。