— 降低風險 · HARD · MCQ —
護理師對一位頭部創傷的病人進行神經學評估，哪項發現是神經狀況惡化最敏感的指標？
A nurse is performing a neurologic assessment on a client with a head injury. Which finding is the most sensitive indicator of deteriorating neurologic status?
- APupillary changes瞳孔變化
- BHeart rate variability心率變異
- CSlurred speech說話含糊不清
- DChange in level of consciousness (LOC)✓ 正解意識層次（LOC）改變
— Explanation · 中文詳解 —
對於頭部創傷的病人，意識程度（Level of Consciousness, LOC）的改變是神經功能惡化最早期且最敏感的指標。當顱內壓（Intracranial pressure）升高時，大腦功能會先出現意識層次的下降（如變得嗜睡、混亂），這往往發生在瞳孔變化或庫欣氏反應（Cushing's triad）之前。早期發現 LOC 改變能爭取搶救機會。
For a client with head injury, a change in level of consciousness (LOC) is the earliest and most sensitive indicator of neurologic deterioration. As intracranial pressure rises, cortical function declines first (drowsiness, confusion), usually before pupillary changes or Cushing's triad appear. Early recognition of LOC change allows timely intervention.