[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-107-2-medical-surgical-032":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":26},"nurse-107-2-內外科護理學-032","nurse-107-2-medical-surgical-032",107,2,32,"張先生，64 歲，因呼吸喘、下肢水腫至急診求治，診斷為心臟衰竭。護理師助張先生作身體檢查與評估時，下列何項檢查因心臟衰竭而可能會有陽性反應發現？",{"A":14,"B":15,"C":16,"D":17},"墨菲氏徵象（Murphy’s sign）","肝頸反流（Hepatojugular reflux）","逆流填充測驗（Retroqrade filling test）","霍曼氏徵象（Homan’s sign）","B",null,[],"本題考點是右心衰竭的身體評估發現。肝頸靜脈回流徵象(hepatojugular reflux)是壓迫肝臟時頸靜脈怒張更明顯,反映右心無法有效回收靜脈回流、體循環鬱血,心臟衰竭病人可見陽性,故選 B。(A)墨菲氏徵象評估膽囊發炎,與心衰無關;(C)逆流填充測驗用於下肢靜脈瓣,非心衰指標;(D)霍曼氏徵象評估深部靜脈栓塞,非心衰特徵。此病人下肢水腫、呼吸喘正符合右心衰竭體循環鬱血表現。","右心衰竭等於體循環鬱血:頸靜脈怒張、肝頸回流陽性、肝腫大、下肢水腫、腹水。左心衰竭等於肺循環鬱血:呼吸困難、端坐呼吸、陣發性夜間呼吸困難、肺囉音、粉紅泡沫痰。此題呼吸喘加下肢水腫提示右心或雙側衰竭。中心靜脈壓上升是右心衰的血流動力指標。",[24,27,30,32],{"term":25,"count":26},"心臟衰竭",7,{"term":28,"count":29},"右心衰竭",3,{"term":31,"count":29},"體循環鬱血",{"term":33,"count":34},"肝頸靜脈回流",1,[36,40,45,49,54,59],{"webId":37,"stem":38,"number":39,"year":9,"session":10},"nurse-107-2-medical-surgical-033","有關降低心衰竭病人心臟後負荷之措施，下列何者正確？",33,{"webId":41,"stem":42,"number":43,"year":44,"session":34},"nurse-108-1-medical-surgical-049","有關全身性紅斑性狼瘡的護理措施，下列何者錯誤？",49,108,{"webId":46,"stem":47,"number":48,"year":44,"session":10},"nurse-108-2-medical-surgical-063","改善其酸鹼不平衡問題最有效的措施，下列何者正確？",63,{"webId":50,"stem":51,"number":52,"year":53,"session":34},"nurse-110-1-medical-surgical-021","下列何者為費林氏測驗（Phalen’s test）陽性反應的描述？",21,110,{"webId":55,"stem":56,"number":57,"year":58,"session":34},"nurse-111-1-medical-surgical-065","有關酸鹼不平衡之敘述，下列何者錯誤？",65,111,{"webId":60,"stem":61,"number":62,"year":63,"session":10},"nurse-112-2-medical-surgical-019","承上題，下列何者為病人最適當的處置？",19,112,"2026-09-04",1788510725178]