— 降低風險 · HARD · MCQ —
護理師照護一位放置蛛網膜下腔壓力監測器的病人，哪項發現顯示可能出現併發症？
A nurse is caring for a client with a continuous subarachnoid pressure monitor. Which finding indicates a potential complication?
- ASteady ICP reading of 10 mmHg顱內壓（ICP）讀數穩定在 10 mmHg
- BClear CSF drainage at the insertion site插入部位有清澈的腦脊髓液引流
- CSlight variation in ICP with coughing咳嗽時顱內壓輕微波動
- DIncreased temperature and purulent drainage✓ 正解體溫升高且有膿性分泌物
— Explanation · 中文詳解 —
腦內壓監測器為侵入性裝置，最嚴重的併發症為腦膜炎或顱內感染。體溫升高伴隨膿性分泌物是感染的典型指標。清澈的腦脊髓液可能是正常滲漏或導管位置正確之表現；ICP 隨咳嗽輕微波動屬正常生理反應；10 mmHg 為正常顱內壓範圍。
Increased temperature and purulent drainage are signs of intracranial infection, such as meningitis, which is a serious complication of invasive monitoring. Normal findings include steady ICP within range, slight ICP variations with coughing, and clear CSF drainage.
✦ 台美臨床差異
美國護理師常需依醫囑進行導管採樣與消毒；台灣則由醫師執行換藥與採樣，護理師負責觀察感染徵象。