# 一位懷孕 34 週的個案主訴劇烈頭痛和視力模糊。血壓為 164/108 mm Hg。護理師的優先行動是什麼？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394058&lang=zh-tw  
> language: zh-TW  
> subject: Lifestyle Choices  
> category: HPM

## 題目

一位懷孕 34 週的個案主訴劇烈頭痛和視力模糊。血壓為 164/108 mm Hg。護理師的優先行動是什麼？

## 選項

1. 通知醫師，並準備進一步評估子癇前症。 **✔ 正確答案**
2. 向個案保證頭痛是懷孕後期的預期現象。
3. 鼓勵個案散步 20 分鐘，然後重新測量血壓。
4. 提供低鈉點心，並讓個案出院回家。

**正確答案: 1**

## 解析

嚴重高血壓伴隨頭痛和視覺症狀，暗示為具嚴重特徵的子癇前症。護理師應通知醫師，並準備進行緊急評估和處置。安撫、運動或出院可能會延誤治療，增加母體和胎兒風險。

## 深入解析

臨床判斷
懷孕期間，嚴重高血壓加上神經學症狀是一種危險模式。

記憶提示
頭痛、視力、高血壓：想到子癇前症。

## 臨床情境

臨床實務指引
子癇前症警訊包括劇烈頭痛、視力變化、嚴重高血壓、腹痛，以及與懷孕風險相關的腫脹。

注意事項
切勿將嚴重症狀視為常規懷孕不適來處理。

## 重要概念

- **子癇前症** — 一種涉及高血壓和潛在器官功能障礙的妊娠疾病。
- **嚴重特徵** — 如嚴重高血壓、神經學症狀或器官損傷等發現。
- **視力模糊** — 一種視覺症狀，可能表示子癇前症影響到神經系統。

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