護理師評估顱內壓（ICP）升高的病人，應向醫師報告哪些發現？（選所有適合的）
A nurse is assessing a client with signs of increasing intracranial pressure (ICP). Which findings should the nurse report to the physician? (Select all that apply.)
- AWidening pulse pressure✓ 正解脈壓差變寬
- BBradycardia✓ 正解心動過緩
- CIrregular respirations✓ 正解呼吸不規則
- DTachycardia心動過速
- EPupillary changes (e.g., fixed/dilated pupil)✓ 正解瞳孔變化（例如：固定/散大）
庫欣氏三徵（Cushing's triad）是 ICP 升高末期的致命警訊：收縮壓升高（脈壓差變大）、心跳減慢（Bradycardia）、呼吸不規律。此外，瞳孔變化（如單側散大、對光反射遲鈍）也顯示大腦壓迫嚴重。心跳過速（Tachycardia）通常與休克或疼痛相關，而非典型 ICP 升高特徵。
Cushing's triad is the late and life-threatening warning sign of elevated intracranial pressure (ICP): rising systolic blood pressure (widening pulse pressure), bradycardia, and irregular respirations. In addition, pupillary changes (such as unilateral dilation or sluggish light reflex) indicate severe cerebral compression. Tachycardia is typically related to shock or pain rather than being a classic feature of elevated ICP.
美國護理師常需參與神經外科病房的 ICP 監測儀器校正，台灣則多由醫師執行 invasive monitoring，護理師監測觀察為主。