一名 45 歲有高血壓病史的病人出現急性嚴重頭痛、視力模糊，血壓 210/120 mmHg。護理師應優先採取哪項措施？
A 45-year-old client with a history of hypertension reports a sudden onset of severe headache, blurred vision, and a blood pressure of 210/120 mmHg. Which action should the nurse take first?
- APlace the client in a high-Fowler’s position將個案置於高福勒氏臥位
- BPerform a neurological assessment進行神經學評估
- CPrepare for immediate administration of IV antihypertensives✓ 正解準備立即給予靜脈注射抗高血壓藥物
- DAdminister the client's oral anti-hypertensive medication給予個案口服抗高血壓藥物
高血壓急症（hypertensive emergency, BP ≥180/120 + 末端器官損害徵象）的優先動作是準備 IV 降壓藥（C，如 labetalol、nicardipine、nitroprusside）。其他選項：A. 高坐臥位為支持性處置，無法解決核心問題；B. 口服降壓藥對急症太慢；D. 神經學評估雖重要但應與 IV 降壓藥同步進行，IV 降壓藥才是最優先的『動作』。
In a hypertensive emergency characterized by end-organ damage signs, the priority is preparing for immediate intravenous antihypertensive therapy to rapidly lower blood pressure. While neurological assessments and positioning are supportive, they do not address the life-threatening physiological instability as directly as IV medication administration.
美國急診護理師在 Protocol 下可先執行擺位與監測，台灣臨床多需先會診醫師評估後再給予靜脈降壓劑。