— 生理適應 · MEDIUM · MCQ —
一位 45 歲高血壓病史病患主訴突發嚴重頭痛、視力模糊及噁心，血壓 210/130 mmHg。護理師應優先採取何種行動？
A 45-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 for the nurse?
- AAdminister an oral antihypertensive medication給予口服降血壓藥物
- BElevate the head of the bed to 30 degrees✓ 正解將床頭抬高30度
- CObtain an EKG進行心電圖檢查
- DPerform a neurological assessment執行神經學評估
— Explanation · 中文詳解 —
此個案呈現高血壓急症（Hypertensive Emergency）。優先採取降低顱內壓的姿勢，將床頭抬高 30 度有助於促進腦部靜脈回流，減輕顱內壓力。此動作非侵入性且能迅速緩解腦灌流過度問題，為緊急處置的首要步驟。
The client is experiencing a hypertensive emergency with signs of increased intracranial pressure. Elevating the head of the bed to 30 degrees facilitates venous drainage from the brain, thereby reducing intracranial pressure and improving cerebral perfusion as an immediate, non-invasive intervention.
✦ 台美臨床差異
美國護理師常依據特定 Protocol 執行降壓措施，台灣則多嚴格遵循醫囑，即使緊急亦需由醫師親自評估後開立 IV 藥物。