— 照護管理 · MEDIUM · SATA —
對於有高血壓病史的病人，下列哪些發現需護理師立即介入？（選所有適合的）
Which findings in a client with a history of hypertension require immediate attention by the nurse? (Select all that apply.)
- ABlood pressure of 145/90 mmHg血壓 145/90 mmHg
- BSudden onset of severe headache✓ 正解突然發作的嚴重頭痛
- CBlurred vision and confusion✓ 正解視力模糊和意識混亂
- DChest pain radiating to the jaw✓ 正解輻射至下顎的胸痛
- EMild pedal edema輕微足部水腫
— Explanation · 中文詳解 —
高血壓急症（Hypertensive Crisis）的警訊包括器官損害徵兆：劇烈頭痛（腦出血/水腫）、視力模糊與意識混亂（高血壓腦病變）、胸痛（心肌缺血/剝離）。A 選項為一般高血壓分級；E 選項多為慢性高血壓常見合併症，非急性器官損傷。
Injury prevention for toddlers should prioritize keeping hot liquids out of reach, installing cabinet locks on cleaning supplies, using cordless window blinds to prevent strangulation, and placing gates at the top and bottom of stairs. These measures address common hazards such as burns, poisoning, falls, and suffocation in active, curious toddlers.
✦ 台美臨床差異
台美對高血壓急症的定義與處置流程高度一致，均重視 end-organ damage 的評估。