# 一位創傷性腦損傷的病人出現顱內壓升高的徵象。哪項護理措施是適當的？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394086&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

一位創傷性腦損傷的病人出現顱內壓升高的徵象。哪項護理措施是適當的？

## 選項

1. 保持床頭平放，頸部彎曲。
2. 將床頭抬高約 30 度，並保持頸部正中位置。 **✔ 正確答案**
3. 僅每 4 小時集中進行抽痰和翻身。
4. 鼓勵用力咳嗽以降低壓力。

**正確答案: 2**

## 解析

對於顱內壓升高，將頭部置於正中位置並抬高床頭，有助於促進靜脈回流。頸部彎曲、長時間集中護理和用力咳嗽都可能增加顱內壓。護理師也應密切監測神經學狀態。

## 深入解析

臨床判斷
顱內壓照護透過改善靜脈回流和避免壓力驟升來保護腦灌注。

記憶提示
頭抬高，頸部直。

## 臨床情境

臨床實務指引
神經學照護包括呼吸道支持、氧合、頭部擺位、頻繁評估及預防次發性腦損傷。

注意事項
突然的神經學惡化需要立即通報升級。

## 重要概念

- **顱內壓** — 顱骨內的壓力，升高時會損害腦灌注。
- **腦灌注** — 供應腦組織氧氣和營養的血流。
- **正中位置** — 支持靜脈回流的頭頸部正中對齊。

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