— 降低風險 · HARD · MCQ —
護理師照護一位顱內壓（ICP）升高的病人，下列哪項措施優先？
Which intervention is priority in the management of a client with increased intracranial pressure (ICP)?
- AKeep the neck in a flexed position保持頸部屈曲姿勢
- BMaintain head of bed at 30 degrees✓ 正解維持床頭抬高30度
- CEncourage deep breathing and coughing鼓勵深呼吸和咳嗽
- DCluster all nursing care to ensure rest集中所有護理工作以確保休息
— Explanation · 中文詳解 —
顱內壓高病人需保持頭部正中位並抬高 30 度，以促進靜脈回流。咳嗽、過度吸痰及頸部屈曲均會增加腹內壓或胸內壓，進而阻礙腦部靜脈回流，導致顱內壓飆升。集中護理（Cluster care）雖然可以休息，但需避免過程造成血壓瞬間升高。
Clients with increased intracranial pressure (ICP) should have the head of bed elevated to 30 degrees with the head in a midline position to promote venous return. Coughing, excessive suctioning, and neck flexion increase intra-abdominal or intrathoracic pressure and impede cerebral venous drainage, raising ICP. Clustering care can allow rest but must be balanced to avoid sudden surges in blood pressure during prolonged procedures.
✦ 台美臨床差異
美台對於 ICP 監測與照護的標準流程一致，美國護理師常配合腦室引流管執行給藥與監控。