— 生理適應 · HARD · MCQ —
一位頭部外傷病患，下列哪項評估發現暗示顱內壓 (ICP) 可能升高？
A nurse is caring for a client with a closed head injury. Which assessment finding indicates a potential increase in intracranial pressure (ICP)?
- APupillary constriction with light reactivity瞳孔縮小且有對光反應
- BTachypnea with deep, irregular breathing呼吸急促伴隨深層且不規則的呼吸
- CBradycardia with widening pulse pressure✓ 正解心跳過緩伴隨脈壓差擴大
- DTachycardia with hypotension心跳過速伴隨低血壓
— Explanation · 中文詳解 —
庫欣氏三徵（Cushing's Triad）包括心搏過緩、呼吸不規則及血壓上升（脈壓變大），為顱內壓急劇升高導致腦幹受壓的晚期徵象。心搏過緩是因為血壓過高反射性引起，與休克時的心搏過速明顯不同，這點在鑑別診斷上極為重要。
Bradycardia with a widening pulse pressure is a key component of Cushing’s triad, indicating increased intracranial pressure and brainstem compression. This reflexive bradycardia occurs in response to severe hypertension and distinguishes increased ICP from other conditions like hypovolemic shock, which presents with tachycardia.
✦ 台美臨床差異
美國護理師常使用神經評估量表（GCS/NIHSS）作為標準，台灣部分醫院仍依賴傳統神經學徵象觀察。