[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-108-1-fundamental-nursing-013":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":35,"lastmod":62},"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-108-1-基本護理學與護理行政-013","nurse-108-1-fundamental-nursing-013",108,1,13,"朱太太 32 歲，因盲腸破裂引發腹膜炎而入院開刀，目前是手術後第二天，TPR：37.5℃、80 次\u002F分、 28 次\u002F分；BP：146\u002F90 mmHg；皺著眉頭一臉痛苦的告訴護理人員：「腹部傷口很痛，整晚都不敢翻身，也睡不著，現在全身都不舒服……」。張護理師針對上述情形為朱太太下了「手術後傷口疼痛」的健康問題，並以 SOAP 方式記錄，則下列何種記錄錯誤？",{"A":15,"B":16,"C":17,"D":18},"「S」：主訴腹部傷口很痛，整晚都不敢翻身","「O」：手術後第二天，皺著眉頭一臉痛苦的陳述，TPR：37.5℃、80 次\u002F分、28 次\u002F分；BP：146\u002F90 mmHg","「A」：傷口感染引發傷口疼痛","「P」：以無菌技術換藥；教導翻身時可以輕壓傷口慢慢翻身；教導減輕疼痛的方法","C",null,[],"本題考點為SOAP護理記錄中各欄位的正確歸類，特別是A（評估／護理診斷）的內容。依SOAP格式，A欄應寫下依S與O資料所形成的護理診斷或問題判斷；本題護理診斷是「手術後傷口疼痛」，但選項C的A欄卻寫「傷口感染引發傷口疼痛」，既與所立診斷不符，情境中也無感染的客觀證據（體溫僅37.5度、無膿或紅腫描述），屬錯誤推論，故C為錯誤記錄，選C。A欄的S記錄病人主訴傷口很痛正確；B的O記錄客觀觀察與生命徵象正確；D的P記錄換藥與減痛衛教等計畫正確。故答案為C。","SOAP要件：S（Subjective）病人主觀陳述、O（Objective）可觀察或測量的客觀資料、A（Assessment）依S、O做的判斷或護理診斷、P（Plan）處置計畫。本題陷阱是把「疼痛」擅自升級為「感染引發」，在缺乏感染徵象下屬過度診斷。記錄鐵律：A欄結論必須有S、O資料支持，不能無中生有加上未證實的病因。",[25,28,31,33],{"term":26,"count":27},"客觀資料",14,{"term":29,"count":30},"SOAP記錄",2,{"term":32,"count":30},"護理診斷",{"term":34,"count":11},"評估欄書寫",[36,39,43,48,52,57],{"webId":37,"stem":38,"number":27,"year":10,"session":11},"nurse-108-1-fundamental-nursing-014","有關核對及執行醫囑的注意事項，下列何者錯誤？",{"webId":40,"stem":41,"number":42,"year":10,"session":30},"nurse-108-2-fundamental-nursing-030","陳先生罹患糖尿病，醫囑開立 RI 20U S.C. tid A.C.，以胰島素空針注射之技術，下列何者錯誤？",30,{"webId":44,"stem":45,"number":46,"year":47,"session":11},"nurse-109-1-fundamental-nursing-044","王先生中風後，有吞嚥困難，現協助其由口進食，下列措施何者不適當？",44,109,{"webId":49,"stem":50,"number":30,"year":51,"session":30},"nurse-110-2-fundamental-nursing-002","下列何種情況出現時只需要記錄，不需要報告？",110,{"webId":53,"stem":54,"number":55,"year":56,"session":30},"nurse-111-2-fundamental-nursing-046","張先生長期仰臥在床上，若未採取預防措施，其髖關節最容易發生何種變化？",46,111,{"webId":58,"stem":59,"number":60,"year":61,"session":30},"nurse-112-2-fundamental-nursing-080","有 10 位急診病患同時到達，由於當天上班的護理師技術熟練且資深，護理長就將任務交待後即離去。護理長是運用 Douglass 提出的那一種領導型態？",80,112,"2026-09-04",1788510708860]