— 生理適應 · HARD · SATA —
護理師應將下列哪些臨床表徵視為顱內壓（ICP）升高的晚期徵象？（選所有適合的）
Which of the following clinical manifestations should a nurse identify as a late sign of increased 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
- DPupillary dilation on the side of the lesion✓ 正解病變側瞳孔擴大
- EProjectile vomiting噴射性嘔吐
— Explanation · 中文詳解 —
庫欣三聯徵（Cushing's triad）是 ICP 升高的典型晚期徵象，包含脈壓差變大、心跳過慢與呼吸不規則。瞳孔不等大或患側擴大則代表腦幹受壓迫的晚期跡象。噴射性嘔吐則是早期至中期徵象，並非晚期特徵。
Late signs of increased intracranial pressure include widening pulse pressure, bradycardia, and irregular respirations, which constitute Cushing’s triad, as well as pupillary dilation indicating potential herniation. Projectile vomiting is generally considered an earlier sign rather than a late indicator.
✦ 台美臨床差異
美國重症護理中會使用 ICP 監測器（如 EVD），台灣除神經外科病房外，亦常見於 ICU 跨團隊照護。