還有更多這樣的題目挑戰 ›

一名護理師於神經重症加護病房照顧裝有外部腦室引流(EVD)的35歲嚴重外傷性腦損傷病人。下列何者顯示顱內壓(ICP)升高,需立即通知醫師?(複選)

Select All That Apply

選擇作答後，查看答案。

1 Bilateral pupils 3 mm equal and reactive to light 雙側瞳孔3 mm等大、對光反射正常 2 Decreased level of consciousness with new pupillary asymmetry 意識降低合併新發瞳孔不對稱 3 BP 122/78, HR 76, RR 16, awake and oriented to person, place, and time BP 122/78、HR 76、RR 16、人時地清醒正常 4 Cushing triad: BP 188/52 mmHg, HR 48 bpm, irregular respirations Cushing三聯症: BP 188/52 mmHg、HR 48、不規則呼吸 5 Sudden vomiting without nausea and severe headache 無噁心之突發嘔吐與劇烈頭痛

查看答案

相同主題的下一題A nurse is caring for an alert adult client with type 1 diabetes who reports tremors, swea…本題收錄於此題庫[전통+신유형] NCLEX LEVEL UP 패키지KRW 79,000

僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。