頭部外傷病人出現下列哪項發現，表示顱內壓（ICP）可能升高？
Which assessment finding in a client with a head injury indicates a potential increase in intracranial pressure (ICP)?
- ATachypnea呼吸急促
- BDilated, nonreactive pupil✓ 正解瞳孔擴大且對光無反應
- CLowering of blood pressure血壓下降
- DIncreased urinary output尿量增加
顱內壓（ICP）升高是頭部外傷後的嚴重併發症。當 ICP 升高，腦組織受到壓迫，會影響腦神經功能。動眼神經（CN III）對壓力極為敏感，受壓時會導致患側瞳孔放大且對光反射消失。此外，護理師需監測「庫欣氏三徵（Cushing's triad）」，即血壓升高、心搏過緩、呼吸不規則，這些均為腦壓升高的危險訊號，需立即處理以防腦疝（Brain herniation）。
Elevated intracranial pressure (ICP) is a serious complication of head trauma. When ICP rises, brain tissue is compressed, impairing neurologic function. The oculomotor nerve (CN III) is highly sensitive to pressure, and compression results in a dilated, nonreactive pupil on the affected side. In addition, the nurse must monitor for Cushing's triad - elevated blood pressure, bradycardia, and irregular respirations - all warning signs of elevated ICP that require immediate intervention to prevent brain herniation.