— 生理適應 · HARD · MCQ —
一名 55 歲高血壓病史病人突發劇烈頭痛、視力模糊及意識混亂。血壓為 210/130 mmHg。護理師優先採取的行動為何？
A 55-year-old client with a history of hypertension reports a sudden onset of severe headache, blurred vision, and confusion. Blood pressure is 210/130 mmHg. Which nursing action is the priority?
- AAdminister an oral antihypertensive medication給予口服降壓藥物
- BInitiate continuous hemodynamic monitoring開始連續血流動力學監測
- CObtain a neurological assessment✓ 正解進行神經學評估
- DPlace the client in a low-Fowler's position將病患置於低福勒氏姿勢（low-Fowler's position）
— Explanation · 中文詳解 —
此個案呈現高血壓急症（Hypertensive Emergency），神經系統功能評估為首要，以鑑別是否有急性腦血管損傷。隨後需進行靜脈降壓藥治療與持續血流動力學監測。口服藥物降壓速度過慢且難以精確控制，不適於危急狀態；平臥位雖可增加腦灌流，但在高血壓急症下應先進行全面神經學檢查與穩定。
In a hypertensive emergency with signs of end-organ damage, obtaining a comprehensive neurological assessment is the priority to determine the extent of injury and establish a baseline. While positioning and monitoring are important, assessing neurological status guides immediate interventions such as intravenous antihypertensive therapy.
✦ 台美臨床差異
美國多由急性照護專科護理師或醫師啟動靜脈給藥；台灣基層單位需立即報告醫師，由醫師給予降壓醫囑。