一位 55 歲高血壓病史病患主訴劇烈頭痛、視力模糊及噁心，血壓 210/130 mmHg。護理師應優先採取何種措施？
A 55-year-old client with a history of hypertension reports a sudden, severe headache, blurred vision, and nausea. The blood pressure is 210/130 mmHg. Which action is the priority?
- APerform a neurological assessment to rule out stroke進行神經學評估以排除中風
- BAdminister an oral antihypertensive medication給予口服降壓藥物
- CPlace the client in a supine position將病人置於仰臥姿勢
- DPrepare for the administration of IV antihypertensive agents✓ 正解準備給予靜脈注射降壓劑
此個案呈現高血壓急症（Hypertensive Emergency），需立即使用靜脈注射血管擴張劑，以防止器官受損。口服藥物藥效太慢，平躺會增加顱內壓，神經學檢查應同時進行但非穩定血壓的緊急優先順序。核心目標為在嚴密監控下迅速降低血壓。
This client is experiencing a hypertensive emergency, indicated by severely elevated blood pressure and signs of end-organ damage such as headache and blurred vision. The priority action is to prepare for intravenous antihypertensive agents, as they allow for rapid, titratable blood pressure reduction to prevent further organ injury. Oral medications act too slowly, and supine positioning may increase intracranial pressure.
美國加護病房與急診對於高血壓急症常有標準 IV 滴注 Protocol，台灣則高度仰賴醫師開立各別醫囑。