A nurse is caring for an unconscious client with increased i… | 마이메르시 MyMerci
Adult Health
문제
A nurse is caring for an unconscious client with increased intracranial pressure (ICP). Which nursing intervention should be the priority to prevent further elevation of ICP?
1Perform frequent neurological assessments every 15 minutes
2Maintain the client in a supine position with legs elevated
3Encourage family members to talk to the client continuously
4Position the client's head in neutral alignment with head of bed elevated 30 degrees✓ 정답
해설
Proper head positioning (HOB elevated 30°, neutral alignment) is the priority intervention to reduce ICP by optimizing venous drainage and decreasing cerebral blood volume. Frequent neuro checks are for monitoring, supine with legs elevated worsens venous congestion, and continuous talking may increase metabolic demand.
錯誤選項分析 (Distractor Analysis) 混淆注意！ ① 執行頻繁的神經學評估：這是非常重要的監測措施（如每15-30分鐘評估一次格拉斯哥昏迷量表 (GCS, Glasgow Coma Scale)、瞳孔反應、生命徵象），目的是「偵測」ICP的變化，而非「預防」其進一步升高。題幹問的是「預防 (prevent)」，因此監測並非最優先的「預防性」措施。 混淆注意！ ② 維持病患平躺且抬高下肢：這是嚴重錯誤的姿勢。抬高下肢會增加中心靜脈壓 (CVP, Central Venous Pressure)，進而阻礙腦部靜脈血液回流，導致顱內靜脈鬱血，反而會使ICP顯著升高，絕對禁止用於ICP升高的病患。 混淆注意！ ③ 鼓勵家屬持續與病患說話：對於意識不清的病患，持續的聽覺刺激可能會增加其腦部的代謝需求，理論上可能加重大腦的氧氣消耗，對降低ICP沒有幫助，甚至可能有害。安靜的環境以減少不必要的刺激，才是護理原則之一。