[{"data":1,"prerenderedAt":62},["ShallowReactive",2],{"q-nurse-107-2-medical-surgical-002":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":32,"lastmod":61},"內外科護理學","medical-surgical",{"id":7,"webId":8,"year":9,"session":10,"subject":4,"number":10,"stem":11,"options":12,"answer":17,"answerNote":18,"images":19,"explanation":20,"explanationDeep":21,"topics":22,"freq":10},"nurse-107-2-內外科護理學-002","nurse-107-2-medical-surgical-002",107,2,"有關維持頭部手術後病人腦組織灌流壓之措施，下列何者錯誤？",{"A":13,"B":14,"C":15,"D":16},"限制液體的攝取量在 1,500～2,000 mL 左右","頭部抬高 30 度","維持排便正常避免用力咳嗽","注意顱內壓升高的症狀及徵象：如心搏過速、血壓升高等","D",null,[],"本題考點是維持腦組織灌流壓、預防顱內壓升高的護理措施辨識,要選出錯誤者。顱內壓升高(IICP)的代償反應為庫欣三聯徵:血壓升高(脈壓變大)、心搏過緩與呼吸型態改變,故 D 將徵象寫為「心搏過速」錯誤,正確應為心搏過緩。A 正確:限制液體攝取(約 1,500–2,000 mL)可避免腦水腫惡化。B 正確:頭部抬高約 30 度有助靜脈回流、降低顱內壓,且不影響腦灌流。C 正確:維持排便通暢、避免用力咳嗽或閉氣用力(Valsalva),可防止胸腹腔壓力驟升而使顱內壓上升。唯 D 的心搏描述與 IICP 生理相反,故為錯誤。","腦灌流壓 CPP=MAP−ICP,護理目標在維持足夠 CPP 又不加劇 IICP。庫欣三聯徵(Cushing's triad)是 IICP 晚期腦幹受壓的警訊:收縮壓升高、脈壓變寬、心搏過緩、呼吸不規則(如 Cheyne-Stokes),代表代償瀕臨失敗。常見誘答就是把「心搏過緩」偷換成「心搏過速」。護理避免一切使顱內壓上升的動作:抬頭 30 度、頸部中立、避免 Valsalva、控制發燒與躁動。",[23,25,27,30],{"term":24,"count":10},"腦灌流壓CPP",{"term":26,"count":10},"心搏過緩",{"term":28,"count":29},"顱內壓升高IICP",1,{"term":31,"count":29},"庫欣三聯徵",[33,37,42,46,51,56],{"webId":34,"stem":35,"number":36,"year":9,"session":10},"nurse-107-2-medical-surgical-003","鍾先生自工地 10 公尺高處落下，造成 C3～C5 完全性脊髓損傷，經 119 送達急診，下列敘述何者錯誤？",3,{"webId":38,"stem":39,"number":40,"year":41,"session":29},"nurse-108-1-medical-surgical-019","有關腔症候群的評估與處置，下列何者錯誤？",19,108,{"webId":43,"stem":44,"number":45,"year":41,"session":10},"nurse-108-2-medical-surgical-033","下列何者是瀕死病人最後消失的知覺？",33,{"webId":47,"stem":48,"number":49,"year":50,"session":10},"nurse-109-2-medical-surgical-071","有關低血糖的敘述，下列何者正確？",71,109,{"webId":52,"stem":53,"number":54,"year":55,"session":29},"nurse-111-1-medical-surgical-035","有關缺鐵性貧血病人的護理措施，下列何者正確？①教導病人使用吸管吸食液態鐵劑 ②鼓勵病人飯後服用鐵劑以增加鐵的吸收 ③鼓勵病人多攝取富含維生素 C 的食物 ④注射鐵劑後應避免立即拔出針頭",35,111,{"webId":57,"stem":58,"number":59,"year":60,"session":29},"nurse-112-1-medical-surgical-069","下列何種荷爾蒙分泌過多會導致康氏症候群（Conn’s syndrome）？",69,112,"2026-09-04",1788510724908]