— 生理適應 · HARD · SATA —
頭部外傷病人出現哪些徵象顯示顱內壓（ICP）升高？（選所有適合的）
Which of the following signs in a client with a head injury indicates a rising intracranial pressure (ICP)? (Select all that apply.)
- ADecreased level of consciousness✓ 正解意識狀態降低
- BWidening pulse pressure✓ 正解脈壓差變寬
- CBradycardia✓ 正解心搏過緩
- DIrregular respirations✓ 正解呼吸不規則
- ETachycardia心搏過速
— Explanation · 中文詳解 —
庫欣氏三徵候（Cushing's triad）是 ICP 升高的經典徵象，包括：脈壓增大（Widening pulse pressure）、心跳變慢（Bradycardia）與呼吸異常。此外，意識層次改變（LOC 下降）亦為極早期指標。心跳加速（Tachycardia）通常與休克相關，非 ICP 升高表現。
Signs of rising intracranial pressure include decreased level of consciousness, widening pulse pressure, bradycardia, and irregular respirations. These symptoms reflect Cushing's triad and brainstem compression, whereas tachycardia typically indicates hypovolemia rather than increased ICP.
✦ 台美臨床差異
美台皆強調 Cushing's triad 的識別，但美國護理師在神經 ICU 執行的監測更為細緻。