[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-106-1-maternal-pediatric-049":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":34,"lastmod":63},"產兒科護理學","maternal-pediatric",{"id":7,"webId":8,"year":9,"session":10,"subject":4,"number":11,"stem":12,"options":13,"answer":18,"answerNote":19,"images":20,"explanation":21,"explanationDeep":22,"topics":23,"freq":10},"nurse-106-1-產兒科護理學-049","nurse-106-1-maternal-pediatric-049",106,1,49,"王小弟，10 歲，頭部外傷住加護病房治療，因病情穩定轉出至兒科病房，然病童仍躁動不安，欲拔除鼻胃管及靜脈注射留置針，經護理評估為了病人安全需給予約束，下列護理措施何者正確？",{"A":14,"B":15,"C":16,"D":17},"配合翻身，每隔 2 小時觀察約束肢體的循環狀態","可採用手臂約束法，將固定帶綁在床欄杆上","可採用雙套結約束法，用棉墊保護雙手，固定於床架上","可採用木乃伊約束法，固定雙手雙腳外，維持頭頸部自由活動","C",null,[],"本題考點為兒童身體約束的安全原則。依約束護理標準,固定帶應綁在「不隨床欄移動的床架」上並以棉墊保護肢體皮膚,雙套結(clove hitch)不會因牽扯而收緊勒傷,故選C正確。A 錯在觀察頻率不足,約束肢體應每 15–30 分鐘評估循環,每 2 小時過長恐延誤發現缺血;B 錯在固定帶綁於「床欄杆」,床欄升降時會拉扯造成傷害,應綁床架;D 錯在木乃伊約束法用於嬰兒短暫全身固定(如頭頸檢查),並非用於固定四肢、且與本情境需求不符。","約束護理的安全核心:「棉墊護膚、綁床架不綁床欄、打不會滑緊的結、密集評估循環」。雙套結(clove hitch)的優點是不隨掙扎收緊,兼顧固定與血流。定時鬆綁活動、觀察膚色溫度脈搏與感覺是必做評估。約束屬限制性措施,須有醫囑、最小化使用並記錄,選項比較時抓『頻率、固定點、結型、方法適應症』四面向即能定位正解。",[24,26,28,30,32],{"term":25,"count":10},"兒童約束護理",{"term":27,"count":10},"雙套結約束法",{"term":29,"count":10},"固定於床架",{"term":31,"count":10},"循環狀態評估",{"term":33,"count":10},"約束安全原則",[35,39,44,49,54,58],{"webId":36,"stem":37,"number":38,"year":9,"session":10},"nurse-106-1-maternal-pediatric-050","小強，15 個月大，被診斷有輕微的腦性麻痺（cerebral palsy）。小強爸爸是個食品公司全職行銷人員，媽媽則在電腦公司上班，家中有請外傭照顧小強，外傭每週一次帶小強去醫院做復健，下列何者為主要的護理措施？",50,{"webId":40,"stem":41,"number":42,"year":9,"session":43},"nurse-106-2-maternal-pediatric-066","盼盼，6 歲，罹患先天性心臟病，依醫囑服用毛地黃，下列何者不是毛地黃中毒的症狀？",66,2,{"webId":45,"stem":46,"number":47,"year":48,"session":10},"nurse-107-1-maternal-pediatric-080","有關妥瑞氏症候群（Tourette's syndrome），下列敘述何者正確？",80,107,{"webId":50,"stem":51,"number":52,"year":53,"session":43},"nurse-108-2-maternal-pediatric-038","有關以子宮托（pessary）減輕子宮脫垂程度，其正確的放置部位為何？",38,108,{"webId":55,"stem":56,"number":43,"year":57,"session":10},"nurse-110-1-maternal-pediatric-002","有關產婦接受腰椎硬膜外麻醉術可能發生的合併症，下列何者錯誤？",110,{"webId":59,"stem":60,"number":61,"year":62,"session":10},"nurse-111-1-maternal-pediatric-036","有關 HPV 疫苗，下列敘述何者正確？",36,111,"2026-09-04",1788510694101]