護理師照護創傷性腦損傷病人，哪些護理措施有助於預防顱內壓（ICP）升高？（選所有適合的）
A nurse is caring for a client with a traumatic brain injury. Which interventions help prevent increased intracranial pressure (ICP)? (Select all that apply.)
- AElevate the head of the bed to 30 degrees✓ 正解將床頭抬高 30 度
- BMaintain neck in a neutral alignment✓ 正解保持頸部中立位置
- CAdminister stool softeners to prevent straining✓ 正解給予軟便劑以防止用力排便
- DEncourage deep breathing and coughing exercises鼓勵深呼吸與咳嗽運動
- EHyperventilate the client to promote vasoconstriction對病人進行過度換氣以促進血管收縮
預防 ICP 升高的核心在於促進腦靜脈回流及避免短暫性壓力增加。頭部抬高 30 度與頸部維持中立位可優化靜脈引流；預防便秘避免用力（Valsalva 動作）可減輕 ICP。鼓勵咳嗽會導致壓力突增，應避免；過度換氣雖可降 ICP，但非護理師可自行決定的常規處置。
To prevent increased intracranial pressure (ICP), nurses should elevate the head of the bed to 30 degrees and maintain the neck in a neutral alignment to facilitate venous drainage. Additionally, administering stool softeners helps prevent the Valsalva maneuver caused by straining, which can spike ICP. Interventions like encouraging coughing or routine hyperventilation are avoided as they may increase intrathoracic pressure or require specific medical orders.
美國重症護理中，護理師依據醫囑執行 ICP 監測的專業度極高；台灣則較強調醫師的主導性與醫囑執行。