— 生理適應 · HARD · MCQ —
一名 55 歲高血壓病史病患出現嚴重頭痛、視力模糊與噁心，血壓 210/130 mmHg。護理師應採取的最優先行動為何？
A 55-year-old client with a history of hypertension reports severe headache, blurry vision, and nausea. Blood pressure is 210/130 mmHg. What is the nurse's priority action?
- APrepare for rapid administration of IV antihypertensive medication✓ 正解準備快速給予靜脈抗高血壓藥物
- BElevate the head of the bed to 45 degrees將床頭抬高 45 度
- CObtain an EKG to check for myocardial strain進行心電圖檢查以評估心肌應變
- DAssess the client's neurological status using the Glasgow Coma Scale使用格拉斯哥昏迷量表評估病人的神經狀態
— Explanation · 中文詳解 —
此個案呈現高血壓急症（Hypertensive Emergency），器官受損（視力、腦部症狀）風險極高。首要目標是降低平均動脈壓以防止進一步受損。A 選項代表針對性的緊急處理，優先級最高。D 和 B 可作為評估步驟，但無法解決造成器官損害的過高血壓。
This client is experiencing a hypertensive emergency, indicated by severe hypertension and signs of target organ damage such as visual changes and headache. The priority action is to prepare for rapid administration of IV antihypertensive medication to lower the mean arterial pressure and prevent further irreversible organ injury.
✦ 台美臨床差異
美國常規使用靜脈藥物如 Labetalol 或 Nicardipine 滴注；台灣臨床則常使用舌下含藥或靜脈注射，且加護病房介入較為普遍。