— 生理適應 · HARD · MCQ —
護理師照護一位腦傷病人。應立即報告哪項評估結果，因為它是顱內壓（ICP）增高晚期的徵兆？
A nurse is caring for a client with a head injury. Which assessment finding should the nurse report immediately as a sign of late-stage increased intracranial pressure (ICP)?
- AWidening pulse pressure✓ 正解脈搏壓變寬
- BPupillary constriction瞳孔收縮
- CIncreased restlessness躁動增加
- DConstant headache持續性頭痛
— Explanation · 中文詳解 —
庫欣氏三病徵（Cushing's Triad）包括收縮壓升高（導致脈搏壓變寬）、心搏緩慢、呼吸不規則，是顱內壓嚴重升高且腦疝風險增加的晚期指標。頭痛（D）與焦躁不安（C）通常是早期徵兆；瞳孔放大（而非收縮）才是 ICP 升高的表現。
Widening pulse pressure is a component of Cushing's triad, which indicates late-stage increased intracranial pressure and impending brain herniation. Early signs of increased ICP include restlessness and headache, while pupillary changes typically involve dilation rather than constriction.
✦ 台美臨床差異
美國 NCLEX 非常強調 Cushing's Triad 的辨識；台灣臨床實務中亦將此列為神經外科觀察重點，但常併用 GCS 評分作為通報依據。