[{"data":1,"prerenderedAt":62},["ShallowReactive",2],{"q-nurse-108-2-fundamental-nursing-012":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":34,"lastmod":61},"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-108-2-基本護理學與護理行政-012","nurse-108-2-fundamental-nursing-012",108,2,12,"以 C.T.M.S.原則評估病人肢體約束時，下列敘述何者正確？",{"A":15,"B":16,"C":17,"D":18},"「C」代表血液循環","「T」代表時間","「M」代表活動能力","「S」代表敏感度","C",null,[],"本題考點為肢體約束後末梢神經血管評估指標C.T.M.S.的字義配對。四者為C=Color(膚色)、T=Temperature(溫度)、M=Movement(活動)、S=Sensation(感覺),目的在及早察覺約束過緊造成的循環障礙或神經壓迫,故「M代表活動能力」正確,選C。A錯:C代表膚色(Color),觀察是否蒼白、發紺,非血液循環。B錯:T代表溫度(Temperature),觸摸末梢冷熱,並非時間。D錯:S代表感覺(Sensation),評估麻木、刺痛等神經感覺,而非儀器測量的「敏感度」。","C.T.M.S.本質是周邊神經血管評估(neurovascular assessment):膚色與溫度反映動脈灌流,感覺與活動反映神經功能,四項合看可分辨是「缺血」還是「神經壓迫」。記憶對比:膚色蒼白\u002F發紺、末梢冰冷指向循環受阻;麻木刺痛、無法活動指向神經受壓。這套指標同樣用於石膏固定、骨折後的肢體觀察,常與「5P」(Pain、Pallor、Pulselessness、Paresthesia、Paralysis)交叉命題。",[25,27,30,32],{"term":26,"count":11},"末梢神經血管評估",{"term":28,"count":29},"C.T.M.S.",1,{"term":31,"count":29},"肢體約束",{"term":33,"count":29},"5P",[35,39,44,48,52,57],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-108-2-fundamental-nursing-013","劉先生因右側股骨頭壞死接受全髖關節置換術，手術後第一天，護理師教導他做股四頭肌等長收縮運動之主要目的不包括下列何者？",13,{"webId":40,"stem":41,"number":42,"year":43,"session":29},"nurse-109-1-fundamental-nursing-029","下列有關體液電解質不平衡之敘述，何者正確？",29,109,{"webId":45,"stem":46,"number":47,"year":43,"session":11},"nurse-109-2-fundamental-nursing-043","病人近端右肱骨骨折已接受石膏固定後之運動，下列何者最不適當？",43,{"webId":49,"stem":50,"number":29,"year":51,"session":29},"nurse-111-1-fundamental-nursing-001","Maslow 的需要階層理論中，最高層級的需要為何？",111,{"webId":53,"stem":54,"number":55,"year":56,"session":29},"nurse-112-1-fundamental-nursing-045","護理師為病人執行鼻胃管灌食，下列措施何者錯誤？",45,112,{"webId":58,"stem":59,"number":42,"year":60,"session":29},"nurse-113-1-fundamental-nursing-029","病人接受靜脈營養，預備轉換為腸道營養的第一階段飲食，下列何者最適當？",113,"2026-09-04",1788510705608]