[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-107-2-fundamental-nursing-041":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":34,"lastmod":63},"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-041","nurse-107-2-fundamental-nursing-041",107,2,41,"李太太，80 歲，身高 160 公分，體重 82 公斤，有糖尿病二十多年，以降血糖藥物控制；近日因左腳疼痛，大拇趾已有壞疽發黑情形，無法下床走路，整天臥床休息，有腹瀉情形，故予以包尿布；今早護理師發現李太太的薦骨處有一處 1 × 2 cm 2 的皮膚呈發紅、腫脹和起水泡情形。下列何者不是造成李太太產生壓瘡的危險因子？",{"A":15,"B":16,"C":17,"D":18},"年齡","肥胖","糖尿病","水腫","D",null,[],"本題考點在壓瘡（壓力性損傷）危險因子的辨識。依 Braden 壓瘡危險因子架構，組織耐受度與壓力暴露是兩大主軸：李太太高齡 80 歲（皮膚變薄、修復慢）、肥胖（BMI 約 32，骨突承受壓力大）、糖尿病二十多年（末梢循環與感覺變差、傷口不易癒合），再加上臥床不動與腹瀉包尿布造成潮濕，都是題幹可對應的危險因子。反觀 D「水腫」，題幹並未描述李太太有水腫表現，就本案例而言不成立，故選 D。A 年齡、B 肥胖、C 糖尿病皆能在病史中找到依據，均為真實存在的危險因子，故非本題所選。","壓瘡成因可拆成「壓力×時間」與「組織耐受度」兩側：外在因子有壓力、剪力、摩擦力、潮濕；內在因子有營養不良、感覺障礙、血液灌流差、年齡。糖尿病同時打擊灌流（小血管病變）與感覺（周邊神經病變），所以糖尿病足與壓瘡常並存。記憶法可用 Braden 六項：感覺、潮濕、活動、移動、營養、摩擦與剪力，分數愈低風險愈高（≤16 分即列高危）。水腫在其他情境確實會降低皮膚耐受度，但本題判斷關鍵是「這位病人有沒有」，而非概念上是否可能。",[25,28,30,32],{"term":26,"count":27},"壓瘡危險因子",1,{"term":29,"count":27},"Braden 壓瘡評估量表",{"term":31,"count":27},"糖尿病周邊血管與神經病變",{"term":33,"count":27},"肥胖與骨突壓力",[35,39,44,48,53,58],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-107-2-fundamental-nursing-042","承上題，針對李太太壓瘡的護理措施，下列敘述何者錯誤？",42,{"webId":40,"stem":41,"number":42,"year":43,"session":27},"nurse-108-1-fundamental-nursing-058","規劃（Planning）就像指南針一樣，引領組織朝著預設的目標前進。某護理機構根據組織與內外在環境的關係，調整機構的願景、價值觀、理念與使命，這是屬於那一種規劃類型？",58,108,{"webId":45,"stem":46,"number":47,"year":43,"session":11},"nurse-108-2-fundamental-nursing-072","護理長授權三班組長保管麻醉藥品，且每班必須清點數目。若麻醉藥品數量出現問題，下列敘述何者正確？",72,{"webId":49,"stem":50,"number":51,"year":52,"session":27},"nurse-110-1-fundamental-nursing-030","溫水拭浴是同時運用下列那二種能量轉移方式，而達到降溫效果？①輻射 ②蒸發 ③傳導 ④對流",30,110,{"webId":54,"stem":55,"number":56,"year":57,"session":27},"nurse-111-1-fundamental-nursing-074","在衝突的發展過程中，那一個階段最適合運用衝突處理技巧來避免非功能性衝突繼續擴大？",74,111,{"webId":59,"stem":60,"number":61,"year":62,"session":11},"nurse-112-2-fundamental-nursing-028","方先生，體溫 39.5℃，依醫囑給予溫水拭浴。下列措施何者正確？",28,112,"2026-09-04",1788510724512]