[{"data":1,"prerenderedAt":67},["ShallowReactive",2],{"q-nurse-107-2-fundamental-nursing-008":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":37,"lastmod":66},"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-107-2-基本護理學與護理行政-008","nurse-107-2-fundamental-nursing-008",107,2,8,"病歷記錄正確書寫的原則有那些？①必須包含主觀資料、客觀資料 ②精確的記載病患各項檢查與檢驗數據 ③運用自己習慣性的方式進行記錄，以維持一致性 ④不要按時間發生順序的結構式記錄，以維持其組織性",{"A":15,"B":16,"C":17,"D":18},"①②","①③","②③","③④","A",null,[],"本題考點在於病歷記錄的正確書寫原則。依護理記錄準則，正確原則包含①完整涵蓋主觀與客觀資料，及②精確記載各項檢查與檢驗數據，故選 A（①②）。③錯，記錄須採統一、標準化格式而非個人習慣方式，以利團隊共讀與連續性照護。④錯，護理記錄應「依時間發生順序」如實記載以呈現病情變化，而非刻意不按時序。因此僅①②為正確原則，其餘兩項皆違反可讀性與法律要件。","護理記錄要件口訣「真、準、全、時、簽」：真實客觀不臆測、精確含數據、完整涵蓋主客觀、及時依時序記錄、簽名可追溯。書寫忌用個人簡稱與塗改（更正須劃線、註記、簽名）。記錄兼具溝通、法律證據與品質稽核功能，故須標準化格式（如 SOAPIE、focus DAR）而非各行其是。時間序列是重建臨床事件與釐清責任的基礎，任意跳序將削弱其法律與臨床價值。",[25,28,30,33,35],{"term":26,"count":27},"主觀與客觀資料",5,{"term":29,"count":11},"護理記錄原則",{"term":31,"count":32},"標準化格式",1,{"term":34,"count":32},"時間順序記錄",{"term":36,"count":32},"病歷法律要件",[38,42,47,51,56,61],{"webId":39,"stem":40,"number":41,"year":10,"session":11},"nurse-107-2-fundamental-nursing-009","有關同理心與同情心的敘述，下列何者正確？",9,{"webId":43,"stem":44,"number":45,"year":46,"session":32},"nurse-108-1-fundamental-nursing-025","下列血品何者可以增加血液膠體滲透壓？",25,108,{"webId":48,"stem":49,"number":50,"year":46,"session":11},"nurse-108-2-fundamental-nursing-039","下列何種臥位不適合意識不清病人口鼻腔分泌物之引流？",39,{"webId":52,"stem":53,"number":54,"year":55,"session":11},"nurse-109-2-fundamental-nursing-077","某護理師平時表現佳，但在年底進行年度考績評核前，因某事與護理長發生爭執，以致護理長對其年度考核評值分數偏低，這是屬於下列何者？",77,109,{"webId":57,"stem":58,"number":59,"year":60,"session":32},"nurse-111-1-fundamental-nursing-041","關於脈搏測量方式的描述，下列何者錯誤？",41,111,{"webId":62,"stem":63,"number":64,"year":65,"session":32},"nurse-112-1-fundamental-nursing-075","衝突的發展過程中，當個體感受知覺衝突，且產生情緒反應時，屬於下列那一個階段？",75,112,"2026-09-04",1788510724162]