[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-108-1-fundamental-nursing-054":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":33,"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":11},"nurse-108-1-基本護理學與護理行政-054","nurse-108-1-fundamental-nursing-054",108,1,54,"柯老太太，82 歲，身上多處壓瘡傷口，入院時 GCS：E4V5M5，BP：118\u002F78 mmHg，體溫 37.6℃， 24 小時後柯老太太出現下列何種情況需立即報告？",{"A":15,"B":16,"C":17,"D":18},"GCS：E3V4M4","體溫 37.8℃","血壓：98\u002F60 mmHg","白班的輸入量：1050 c.c.，輸出量：650 c.c.","A",null,[],"本題考點是依病情變化判斷何者需立即通報。原則是意識狀態惡化屬神經功能急遽變化的紅旗。入院時昏迷指數為E4V5M5(14分),24小時後A項變為E3V4M4(11分),下降3分且各項退步,顯示意識明顯惡化,可能為顱內或全身病況急轉,需立即報告,故選A。B體溫由37.6℃升為37.8℃僅微幅變化,無立即危險;C血壓由118\u002F78降為98\u002F60雖略降,收縮壓仍近100mmHg,尚在可觀察範圍;D白班輸入1050c.c.、輸出650c.c.,輸出量正常、水分平衡合理,無異常。相較之下,唯A的昏迷指數顯著下降代表病情惡化,最需優先通報。","格拉斯哥昏迷指數(GCS)含睜眼E(1–4)、語言V(1–5)、運動M(1–6),滿分15、最低3;下降≧2分或運動反應退步是神經惡化警訊,須即刻評估與通報。臨床判斷通報優先序:先看攸關生命與神經功能的急遽變化,再看數值輕微波動。本題其餘選項屬正常或輕微變動。可連結意識評估、顱內壓升高徵象與神經系統監測。記憶:「意識掉分,最要命」。",[25,27,29,31],{"term":26,"count":11},"格拉斯哥昏迷指數",{"term":28,"count":11},"意識評估",{"term":30,"count":11},"病情惡化通報",{"term":32,"count":11},"神經功能監測",[34,38,43,48,53,58],{"webId":35,"stem":36,"number":37,"year":10,"session":11},"nurse-108-1-fundamental-nursing-055","鍾先生接受冠狀動脈繞道手術後，轉至一般病房，目前手術傷口疼痛影響睡眠，協助睡眠的處置下列何者適當？①必要時依醫囑給予 Acetaminophen 500 mg\u002Ftab 1 顆 ②睡前給予喝溫紅茶牛奶或吃小點心 ③睡前 1 小時執行四肢關節活動訓練 ④睡前給予溫水拭浴",55,{"webId":39,"stem":40,"number":41,"year":10,"session":42},"nurse-108-2-fundamental-nursing-071","影響護理資訊系統發展因素中，「資訊系統上線時，教育訓練不足」是下列那一類因素影響？",71,2,{"webId":44,"stem":45,"number":46,"year":47,"session":42},"nurse-109-2-fundamental-nursing-005","對於醫囑（order）的描述，下列何者正確？",5,109,{"webId":49,"stem":50,"number":51,"year":52,"session":42},"nurse-110-2-fundamental-nursing-043","下列病人情境，何者適合執行灌腸？",43,110,{"webId":54,"stem":55,"number":56,"year":57,"session":11},"nurse-112-1-fundamental-nursing-007","下列那一項不屬於專業性人際關係的特點？",7,112,{"webId":59,"stem":60,"number":61,"year":57,"session":62},"nurse-112-3-fundamental-nursing-041","有關排班的類型，下列敘述何者正確？",41,3,"2026-09-04",1788510709205]