— 降低風險 · MEDIUM · MCQ —
護理師在開顱手術後對病人進行神經評估，哪項發現應立即報告醫師？
A nurse is performing a neurologic assessment on a client following a craniotomy. Which finding should the nurse report to the surgeon immediately?
- ABlood pressure 135/85 mmHg血壓 135/85 mmHg
- BDrainage of 20 mL of serosanguineous fluid in 8 hours8小時內引流20 mL漿液血性液體
- CDecrease in level of consciousness from alert to lethargic✓ 正解意識水準從清醒下降至嗜睡
- DPupils equal, round, and reactive to light瞳孔等大、圓形且對光有反應
— Explanation · 中文詳解 —
術後意識狀態的改變是顱內壓升高（ICP）最早期的臨床徵兆。從清醒轉為嗜睡暗示大腦灌流不足或繼發性出血，必須立即處理以預防腦疝。其餘選項如少量引流液、正常瞳孔反應及輕度高血壓在術後初期較為常見，但意識改變具備緊急警訊意義。
A decrease in the level of consciousness is the earliest and most critical sign of increased intracranial pressure (ICP) following a craniotomy. This change suggests potential cerebral edema or hemorrhage compromising brain perfusion, requiring immediate notification of the surgeon to prevent irreversible neurological damage or herniation.
✦ 台美臨床差異
台灣醫院常規使用 GCS 監測，美國護理師對意識改變的定義更強調「與基礎值的比較」。