— 生理適應 · HARD · MCQ —
病人的顱內壓（ICP）為 22 mmHg。哪項護理干預措施是適當的？
A client has an intracranial pressure (ICP) of 22 mmHg. Which nursing intervention is appropriate?
- AProvide a vigorous back massage for relaxation提供劇烈的背部按摩以放鬆
- BPosition the client with the head of the bed at 30 degrees✓ 正解將病人床頭抬高30度
- CEncourage coughing and deep breathing鼓勵咳嗽與深呼吸
- DPerform frequent suctioning to keep the airway clear頻繁抽吸以保持呼吸道暢通
— Explanation · 中文詳解 —
顱內壓（Intracranial Pressure, ICP）是顱骨內腦組織、腦脊髓液和血液三者共同產生的壓力。正常成人 ICP 範圍約為 5-15 mmHg。當 ICP 持續升高至 20-25 mmHg 以上時，會對腦組織造成壓迫，導致腦灌流壓（Cerebral Perfusion Pressure, CPP）下降，引起腦缺血，甚至可能導致腦疝（brain herniation）等危及生命的併發症。因此，護理師必須迅速採取干預措施來降低顱內壓，以保護腦功能，避免不可逆的損傷。
An intracranial pressure of 22 mmHg exceeds the normal range, necessitating interventions to promote venous drainage and reduce pressure. Positioning the head of the bed at 30 degrees facilitates this drainage, whereas vigorous massage, coughing, or frequent suctioning can further increase intracranial pressure.