[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-106-1-maternal-pediatric-074":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":32,"lastmod":62},"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-074","nurse-106-1-maternal-pediatric-074",106,1,74,"小芸，1 歲半，因罹患克隆氏症（Crohn’s disease）而接受人工結腸造瘻口手術。小芸母親第一次參與學習腸造瘻口居家護理技巧，下列護理措施及指導何者錯誤？",{"A":14,"B":15,"C":16,"D":17},"手術後造瘻口會有暫時性腫脹情形，持續約 3～6 週後，造瘻口會漸漸縮小開口","好的造瘻口呈紅色，若呈現黑色或深色，表示可能因扭轉、脫出或黏連造成血液循環不佳","將保護膜剪成如造瘻口大小或比造瘻口大約 0.5 公分，貼在造瘻口的周圍皮膚上","造瘻口黏膜需比周圍皮膚低，以保護周圍皮膚及造瘻口的完整，促進傷口癒合","D",null,[],"本題考點為腸造瘻口的居家護理指導。依造瘻口照護原則,健康的造瘻口應高於或平齊周圍皮膚且呈紅潤,以利排泄物流入造口袋、避免滲漏刺激皮膚,故D「造瘻口黏膜需比周圍皮膚低」為錯誤指導。A術後暫時性腫脹約3至6週漸縮小(對);B造瘻口由紅轉黑或深色代表扭轉、脫出或血循不良(對);C保護膜開口剪成與造瘻口同大或大約0.5公分以保護周圍皮膚(對)。造瘻口若凹陷低於皮膚,反而使排泄物滲入皮膚下緣造成糜爛,故D敘述違反照護目標。","理想造瘻口紅潤濕潤、略凸出皮膚(如玫瑰花苞),便於底盤密貼與排泄物導入造口袋。顏色是循環指標:紅潤良好、蒼白貧血、暗紫或黑色代表缺血須即刻評估。底盤開口過大會露出皮膚遭排泄物侵蝕,過小則摩擦造口出血,故剪裁約大於造口0.5公分。凹陷型造口需以凸面底盤加腰帶改善貼合。",[24,26,28,30],{"term":25,"count":10},"腸造瘻口",{"term":27,"count":10},"造口顏色評估",{"term":29,"count":10},"造口袋底盤",{"term":31,"count":10},"周圍皮膚保護",[33,37,42,47,52,57],{"webId":34,"stem":35,"number":36,"year":9,"session":10},"nurse-106-1-maternal-pediatric-075","有關沙門氏菌（Salmonella）感染引致的兒童急性腸胃炎，其大便型態之敘述，下列何者正確？",75,{"webId":38,"stem":39,"number":40,"year":41,"session":10},"nurse-107-1-maternal-pediatric-011","王女士以陰道產娩出一足月男嬰，其第一、五分鐘的 Apgar scores 分別為 7 分和 8 分，新生兒即刻護理已完成，王女士正在進行會陰縫合，有關首次親子互動之時機，下列何者最適當？",11,107,{"webId":43,"stem":44,"number":45,"year":41,"session":46},"nurse-107-2-maternal-pediatric-025","有關 REEDA 評估會陰切開傷口的內容，下列何者正確？",25,2,{"webId":48,"stem":49,"number":50,"year":51,"session":46},"nurse-108-2-maternal-pediatric-063","有關新生兒壞死性腸炎之敘述，下列何者錯誤？",63,108,{"webId":53,"stem":54,"number":55,"year":56,"session":10},"nurse-110-1-maternal-pediatric-027","有關新生兒囟門的敘述，下列何者錯誤？",27,110,{"webId":58,"stem":59,"number":60,"year":61,"session":10},"nurse-111-1-maternal-pediatric-061","小凱，5 歲，入院診斷為右下肺葉肺炎，急性期發生呼吸窘迫症狀，下列護理措施何者較不適當？",61,111,"2026-09-04",1788510694420]