護理師照護一位頭部外傷病人。哪些發現應立即報告？（選所有適合的）
A nurse is caring for a patient with a closed head injury. Which findings should be reported immediately? (Select all that apply.)
- ADecrease in level of consciousness✓ 正解意識程度下降
- BUnequal pupils✓ 正解瞳孔大小不等
- CProjectile vomiting✓ 正解噴射性嘔吐
- DClear fluid draining from the nose✓ 正解鼻腔流出清澈液體
- EStable blood pressure血壓穩定
閉合性頭部外傷（Closed head injury）的核心風險在於顱內壓（Intracranial Pressure, ICP）升高，進而導致腦組織灌流不足或腦疝。護理師需密切監測神經學指標。意識程度下降、瞳孔異常、噴射性嘔吐均是 ICP 升高的典型徵兆（Cushing's triad 的前兆或表現）。此外，鼻漏（Rhinorrhea）若呈現清澈液體，需高度懷疑腦脊髓液（CSF）外漏，這代表顱底骨折，有引發腦膜炎的風險。
The main risk in closed head injury is increased intracranial pressure (ICP), leading to inadequate cerebral perfusion or herniation. The nurse must closely monitor neurological indicators. Decreased LOC, pupillary changes, and projectile vomiting are typical ICP elevation signs (precursors of or part of Cushing's triad). Clear rhinorrhea raises strong suspicion of CSF leak indicating basilar skull fracture, with risk of meningitis.