— 生理適應 · EASY · MCQ —
一名 55 歲高血壓病史病患入院，血壓為 180/110 mmHg。護理師在評估時應優先注意哪項臨床表徵？
A 55-year-old client with a history of hypertension is admitted with a blood pressure of 180/110 mmHg. Which clinical manifestation should the nurse prioritize during the assessment?
- ABilateral pedal edema雙側足部水腫
- BMild blurred vision輕微視力模糊
- COccasional palpitations偶發心悸
- DReport of a severe headache✓ 正解主訴嚴重頭痛
— Explanation · 中文詳解 —
高血壓危象（Hypertensive crisis）的標誌性症狀包括嚴重頭痛、意識改變、視力模糊或胸痛，這是器官損害的警訊。劇烈頭痛顯示顱內壓可能上升或腦血管處於高度壓力狀態，需立即通報並介入處理以防止腦出血。
A severe headache is the priority finding as it may indicate hypertensive encephalopathy or increased intracranial pressure, signaling acute target organ damage. This symptom requires immediate intervention to prevent complications such as stroke or hemorrhage.
✦ 台美臨床差異
台美對於高血壓急症的給藥途徑選擇上，美國護理師有時可依據醫囑透過輸液幫浦滴定控制，台灣多由醫師決定調整頻率。