— 生理適應 · EASY · MCQ —
一位 55 歲高血壓病史病人因血壓 185/110 mmHg 及劇烈頭痛入院。護理師應優先採取何種行動？
A 55-year-old client with a history of hypertension is admitted with a blood pressure of 185/110 mmHg and a severe headache. Which action is the priority?
- AObtain a complete neurologic assessment✓ 正解進行完整的神經學評估
- BPlace the client in a semi-Fowler position將病人置於半坐臥姿勢
- CInitiate IV access建立靜脈通路
- DAdminister an oral antihypertensive medication給予口服抗高血壓藥物
— Explanation · 中文詳解 —
高血壓急症（Hypertensive Emergency）的病人若伴隨劇烈頭痛，極高機率涉及標的器官損傷，特別是腦部。護理師必須優先進行神經學評估（Neurological Assessment），以篩檢是否已有急性腦中風、腦出血或高血壓腦病變的跡象。評估意識狀態（GCS）、瞳孔大小及肢體力量是判斷病情危急程度的關鍵。
In a hypertensive emergency with symptoms like severe headache, the priority is to assess for end-organ damage, particularly neurological deficits indicating a stroke or hemorrhage. While positioning and IV access are important, they follow the immediate need to evaluate the client's neurological status to determine the severity of the condition.