— 生理適應 · MEDIUM · MCQ —
一位 55 歲高血壓病史病人出現突發性劇烈頭痛及視力模糊，血壓為 210/130 mmHg。下列何者為優先行動？
A 55-year-old client with a history of hypertension reports a sudden onset of severe headache and blurred vision. The blood pressure is 210/130 mmHg. Which action is the priority?
- AAdminister oral antihypertensive medication as ordered依醫囑給予口服降血壓藥物
- BPerform a neurological assessment進行神經系統評估
- CPlace the client in a high-Fowler’s position✓ 正解將病人置於高福勒氏臥位（High-Fowler's position）
- DObtain an ECG strip取得心電圖條帶
— Explanation · 中文詳解 —
此個案呈現高血壓急症（Hypertensive Emergency）。首要目標是降低血壓以保護標的器官。採半坐臥姿（High-Fowler's）可減低腦部壓力並緩解呼吸困難。口服藥物作用慢，通常需靜脈注射藥物；ECG 與神經評估是後續步驟，但維持循環與腦部灌流穩定優先。
In a hypertensive emergency with signs of increased intracranial pressure, placing the client in a high-Fowler’s position is the priority action to help reduce cerebral pressure and improve breathing. This immediate positioning stabilizes the client before administering medications or performing further assessments.
✦ 台美臨床差異
美國護理師對高血壓急症藥物給予有明確 protocol，台灣醫療現場通常需醫師開立靜脈藥物醫囑。