— 生理適應 · HARD · SATA —
護理師評估一位頭部受傷後出現庫欣氏三病徵 (Cushing's triad) 的患者。應預期哪些發現？（選所有適合的）
The nurse is assessing a client with Cushing's triad after a head injury. What findings should the nurse expect? (Select all that apply.)
- ABradycardia✓ 正解心跳過緩
- BTachycardia心跳過速
- CWidened pulse pressure✓ 正解脈搏壓增寬
- DIrregular respirations✓ 正解呼吸不規則
- EHypotension低血壓
— Explanation · 中文詳解 —
庫欣氏三病徵是顱內壓（ICP）增高的晚期徵兆，包含：(1) 收縮壓上升導致脈搏壓變寬（Widened pulse pressure）；(2) 心跳過緩（Bradycardia）；(3) 呼吸不規則（Irregular respirations）。這與休克的症狀（血壓降、心跳快）正好相反。
Cushing's triad is a late sign of increased intracranial pressure (ICP) and consists of: (1) a rising systolic pressure producing a widened pulse pressure; (2) bradycardia; and (3) irregular respirations. These findings are the opposite of shock, which presents with hypotension and tachycardia.
✦ 台美臨床差異
NCLEX 常考庫欣氏三病徵與休克的鑑別；台灣臨床多將此視為神經外科照護的核心指標。