— 生理適應 · HARD · MCQ —
頭部外傷病人意識狀況逐漸混亂。護理師應立即進行哪項評估？
A client with a head injury becomes increasingly confused. Which assessment should the nurse perform immediately?
- APupillary response✓ 正解瞳孔反應
- BBowel sounds腸鳴音
- CBlood pressure血壓
- DPeripheral pulse末梢脈搏
— Explanation · 中文詳解 —
頭部外傷病人出現意識狀態惡化（Confused），是顱內壓（ICP）升高或腦出血的危險訊號。瞳孔反應（Pupillary response）受動眼神經控制，是評估腦幹壓迫與顱內壓變化的最快指標。若發生單側瞳孔散大（Pupil dilation）或對光反射遲鈍，代表腦部已受到嚴重壓迫，需即刻處理以防腦疝（Herniation）。
Deterioration in level of consciousness (confusion) in a client with head trauma is a warning sign of rising intracranial pressure (ICP) or intracranial hemorrhage. Pupillary response, controlled by the oculomotor nerve, is the fastest indicator of brainstem compression and changes in ICP. Unilateral pupil dilation or sluggish light reflex indicates severe brain compression, and immediate intervention is required to prevent herniation.