[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-106-2-fundamental-nursing-055":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":34,"lastmod":64},"基本護理學與護理行政","fundamental-nursing","基本護理學(包括護理原理、護理技術)與護理行政",{"id":8,"webId":9,"year":10,"session":11,"subject":4,"number":12,"stem":13,"options":14,"answer":19,"answerNote":20,"images":21,"explanation":22,"explanationDeep":23,"topics":24,"freq":27},"nurse-106-2-基本護理學與護理行政-055","nurse-106-2-fundamental-nursing-055",106,2,55,"一位 50 歲男性，離婚，曾擔任機師已被確診為肺癌末期病人，經歷過化學治療、放射線治療及標靶治療。近日因出現嚴重的喘、呼吸困難及意識改變而入院治療，但因疾病持續進展，目前病人已面臨「瀕死」的階段。此階段病人可能會出現之生理變化，下列何者正確？①希式面容（Facies Hippocratica） ②畢歐氏呼吸（Biot’s respiration） ③鞏膜水腫 ④幻視覺或幻聽覺 ⑤疼痛減弱或消失",{"A":15,"B":16,"C":17,"D":18},"①②⑤","①③④","②④⑤","③④⑤","B",null,[],"本題考點是瀕死階段的生理變化辨識。依瀕死病生理,①希式面容(Facies Hippocratica,眼窩凹陷、鼻尖顴突、面色灰暗)反映嚴重脫水與循環衰竭;③循環衰竭與低蛋白使組織液滯留,可致鞏膜、結膜水腫;④瀕死伴代謝紊亂與腦部缺氧可出現幻視、幻聽,三者成立,故選 B(①③④)。②畢歐氏呼吸(Biot's respiration)是規律呼吸後突然暫停的型態,較常見於腦膜炎或延腦病變,而瀕死者典型的是潮式呼吸(Cheyne-Stokes),故不選;⑤在本題未列入正解組合。本題涉及呼吸型態鑑別與部分症狀認定,把握度略降。","瀕死呼吸型態需分辨:Cheyne-Stokes(潮式,漸強漸弱後暫停,瀕死最典型)、Biot's(叢集式,深度一致後突停,見於腦幹病變)、Kussmaul(深快,見於代謝性酸中毒)。希式面容是古典瀕死徵象。②與⑤的取捨為本題爭議點,是把握度標為 medium 的原因,答案採官方認定。可連結至瀕死徵象評估與潮式呼吸機轉。",[25,28,30,32],{"term":26,"count":27},"希式面容",1,{"term":29,"count":27},"潮式呼吸 Cheyne-Stokes",{"term":31,"count":27},"畢歐氏呼吸鑑別",{"term":33,"count":27},"瀕死生理變化",[35,39,44,49,54,59],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-106-2-fundamental-nursing-056","承上題，此階段護理師給予病人的生理照護措施，下列何者錯誤？",56,{"webId":40,"stem":41,"number":42,"year":43,"session":27},"nurse-107-1-fundamental-nursing-072","根據 Donabedian（1966）所提出的醫療服務品質概念，護理部定期至病房觀察護理師發藥是否有遵照三讀五對，這屬下列那一種考核？",72,107,{"webId":45,"stem":46,"number":47,"year":48,"session":27},"nurse-108-1-fundamental-nursing-006","有關預防住院老人走失的措施，下列何者最為適切？",6,108,{"webId":50,"stem":51,"number":52,"year":53,"session":27},"nurse-109-1-fundamental-nursing-044","王先生中風後，有吞嚥困難，現協助其由口進食，下列措施何者不適當？",44,109,{"webId":55,"stem":56,"number":57,"year":58,"session":11},"nurse-110-2-fundamental-nursing-008","李先生因車禍造成腦部創傷，手術後一個月，生命徵象穩定但意識不清、需長期臥床，此時較合適使用何種方式提供營養？",8,110,{"webId":60,"stem":61,"number":62,"year":63,"session":11},"nurse-111-2-fundamental-nursing-042","王小姐平時血壓為 110～120\u002F76～80 mmHg。則以錶式血壓計測量時，應充氣至下列何壓力值為佳？",42,111,"2026-09-04",1788510697941]