— 生理適應 · HARD · SATA —
護理師照護疑似中風病人，下列哪些發現顯示顱內壓（ICP）增高？（選所有適合的）
A nurse is caring for a client with a suspected stroke. Which findings indicate an increase in intracranial pressure (ICP)? (Select all that apply.)
- AWidening pulse pressure✓ 正解脈壓差變寬
- BIrregular respirations✓ 正解呼吸不規則
- CBradycardia✓ 正解心動過緩
- DTachycardia心動過速
- EProjectile vomiting✓ 正解噴射性嘔吐
— Explanation · 中文詳解 —
庫欣氏三徵（Cushing's triad）包含收縮壓上升導致脈壓差擴大、心跳減慢（Bradycardia）以及呼吸型態異常。這些是顱內壓急遽升高的晚期跡象。噴射狀嘔吐也常見於顱內壓升高，而心跳過速則非典型徵兆。
Increased intracranial pressure (ICP) is indicated by Cushing's triad, which consists of widening pulse pressure, bradycardia, and irregular respirations resulting from brainstem compression. Projectile vomiting is also a common sign of elevated ICP, whereas tachycardia is not a typical manifestation of this condition.
✦ 台美臨床差異
台美臨床對於庫欣氏三徵的辨識標準一致，但在美國護理師更常主動啟動神經學監測 protocol。