[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-106-2-medical-surgical-045":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":35,"lastmod":64},"內外科護理學","medical-surgical",{"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-106-2-內外科護理學-045","nurse-106-2-medical-surgical-045",106,2,45,"有關燒傷傷口臨床表徵的敘述，下列何者正確？",{"A":14,"B":15,"C":16,"D":17},"表淺部分皮層燒傷部位會有水泡形成，中重度疼痛","四度燒傷傷口呈現乾燥、焦黑、中重度疼痛","深二度燒傷傷口皮膚呈現粉紅色、紅腫、劇烈疼痛","三度燒傷傷口皮膚乾燥、受壓不會變蒼白、皮革狀焦痂","D",null,[],"本題考點為燒傷深度分級的臨床表徵鑑別。三度(全層)燒傷破壞整層表皮與真皮含神經末梢,傷口呈乾燥、皮革狀焦痂,受壓不變蒼白(微血管充填消失),且因神經受損反而痛覺遲鈍,D 描述完全符合,選 D。A 表淺部分皮層(淺二度)確有水泡,但其疼痛應為劇烈而非「中重度」,描述偏差;B 四度燒傷傷及肌肉骨骼,焦黑無痛感,『中重度疼痛』錯誤;C 深二度傷口通常較蒼白、濕潤、微血管充填延遲,而『粉紅色、紅腫、劇烈疼痛』較符合淺二度而非深二度。故選 D。","分級對照:淺二度=水泡+濕潤+劇痛(神經完好);深二度=蒼白偏白\u002F斑駁+痛覺減弱;三度=乾燥皮革焦痂+受壓不泛白+無痛(neural destruction);四度=深達肌肉骨骼+焦炭化。判痛覺是關鍵:『愈深愈不痛』,因痛覺纖維被破壞。受壓是否變蒼白(blanching)反映微血管床是否存活,三度以上不再泛白。",[24,26,29,31,33],{"term":25,"count":10},"燒傷深度分級",{"term":27,"count":28},"全層燒傷",1,{"term":30,"count":28},"皮革狀焦痂",{"term":32,"count":28},"痛覺與神經破壞",{"term":34,"count":28},"微血管充填(blanching)",[36,40,45,49,54,59],{"webId":37,"stem":38,"number":39,"year":9,"session":10},"nurse-106-2-medical-surgical-046","有關 HIV 疾病進展的敘述，下列何者錯誤？",46,{"webId":41,"stem":42,"number":43,"year":44,"session":28},"nurse-107-1-medical-surgical-062","末期腎疾病（ESRD）病人需接受透析治療的指標，下列何者錯誤？",62,107,{"webId":46,"stem":47,"number":48,"year":44,"session":10},"nurse-107-2-medical-surgical-076","下列何種荷爾蒙分泌過多會導致肢端肥大症？",76,{"webId":50,"stem":51,"number":52,"year":53,"session":28},"nurse-109-1-medical-surgical-034","有關癌症手術治療特性之敘述，下列何者正確？",34,109,{"webId":55,"stem":56,"number":57,"year":58,"session":28},"nurse-110-1-medical-surgical-078","有關敗血性休克引發瀰漫性血管內凝血（DIC）之敘述，下列何者正確？",78,110,{"webId":60,"stem":61,"number":62,"year":63,"session":10},"nurse-111-2-medical-surgical-032","病人昨天接受冠狀動脈繞道手術（CABG），胸管引流量共 600 mL，今體溫 38.7℃，血壓 100\u002F60 mmHg， SaO 2 94%。下列處置何者錯誤？",32,111,"2026-09-04",1788510698666]