[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-107-2-medical-surgical-019":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":34,"lastmod":63},"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":26},"nurse-107-2-內外科護理學-019","nurse-107-2-medical-surgical-019",107,2,19,"有關軟組織損傷病人的護理評估結果，下列何者顯示可能有腔隙症候群？",{"A":14,"B":15,"C":16,"D":17},"周邊脈搏強度 2+","微血管填充時間小於 3 秒","肢端蒼白、變冷","皮膚出現瘀斑","C",null,[],"本題考點是腔隙(腔室)症候群的早期評估徵象。腔室症候群因肢體筋膜腔內壓升高,壓迫血管神經致循環障礙,典型評估以「6P」為據:疼痛(pain)、蒼白(pallor)、無脈(pulselessness)、感覺異常(paresthesia)、麻痺(paralysis)與冰冷(poikilothermia)。選項 C「肢端蒼白、變冷」正屬循環受阻的表現,可能提示腔室症候群,故選 C。A 錯誤:周邊脈搏強度 2+ 屬正常脈搏,非缺血徵象。B 錯誤:微血管填充時間小於 3 秒代表末梢灌流良好,亦為正常。D 錯誤:皮膚瘀斑多為表淺挫傷或凝血相關,非腔室症候群的特異徵象。唯 C 反映末梢循環不良,與腔室症候群相符。","腔室症候群機轉:密閉筋膜腔內出血或水腫使腔內壓超過微血管灌流壓,造成組織缺血,若未及時筋膜切開減壓,數小時內即可致肌肉神經壞死(Volkmann 攣縮)。早期最敏感的警訊是「與傷勢不成比例的劇痛」與被動牽拉患處肌肉時劇痛;脈搏消失屬晚期徵象,故不可等到無脈才處置。護理評估以 6P 為框架,C 的蒼白冰冷即缺血訊號。此為肢體肌肉骨骼創傷的急症考點。",[24,27,29,32],{"term":25,"count":26},"腔室症候群",4,{"term":28,"count":10},"末梢循環評估",{"term":30,"count":31},"6P徵象",1,{"term":33,"count":31},"缺血性攣縮",[35,39,44,48,53,58],{"webId":36,"stem":37,"number":38,"year":9,"session":10},"nurse-107-2-medical-surgical-020","有關截肢病人的照護，下列何者錯誤？",20,{"webId":40,"stem":41,"number":42,"year":43,"session":31},"nurse-108-1-medical-surgical-036","與乳癌有關的腫瘤標記，下列何者正確？",36,108,{"webId":45,"stem":46,"number":47,"year":43,"session":10},"nurse-108-2-medical-surgical-050","評估右下肺葉時叩診出現濁音及聽診時呼吸音減弱，胸部 X 光檢查結果右側肋膜橫膈角呈鈍角，下列何者為病人最可能之診斷？",50,{"webId":49,"stem":50,"number":51,"year":52,"session":31},"nurse-110-1-medical-surgical-008","有關癲癇病人服用藥物的敘述，下列何者正確？",8,110,{"webId":54,"stem":55,"number":56,"year":57,"session":31},"nurse-111-1-medical-surgical-052","有關使用呼氣末期陽壓（PEEP）治療急性呼吸窘迫症候群的主要目的，下列何者正確？",52,111,{"webId":59,"stem":60,"number":61,"year":62,"session":10},"nurse-112-2-medical-surgical-006","張先生因高處跌下導致脊髓損傷住院，護理師可經由下列何種反射出現，而知張先生已渡過脊髓休克期？",6,112,"2026-09-04",1788510725060]