[{"data":1,"prerenderedAt":67},["ShallowReactive",2],{"q-nurse-108-2-fundamental-nursing-055":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":36,"lastmod":66},"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-108-2-基本護理學與護理行政-055","nurse-108-2-fundamental-nursing-055",108,2,55,"10\u002F09 羅先生由高處跌落，多處肋骨斷裂，有急性疼痛的問題，主責護理師於 9：30 AM 給予止痛劑，下列何者為最適當護理評值之紀錄？",{"A":15,"B":16,"C":17,"D":18},"10\u002F09 10 AM 病人主訴疼痛指數為 7 分","10\u002F09 10 AM 病人主訴疼痛改善，疼痛指數已由 7 分降至 4 分","10\u002F09 10 AM 病人能說出緩解疼痛的方法二項，如深呼吸、放鬆肌肉","10\u002F09 10 AM 病人能用助行器下床活動，且無呼吸喘的徵象","B",null,[],"本題考點為護理評值（evaluation）紀錄應對照護理目標、呈現病人反應與成效。針對「急性疼痛」問題、於9:30給藥後的評值，應記錄疼痛此一問題在措施後的改變情形。B「疼痛指數已由7分降至4分」直接以量化指標呈現止痛措施後疼痛減輕的成效，正是對應疼痛目標的評值紀錄，故為答案。A僅記錄疼痛7分屬給藥前或當下的評估數據，未顯示介入後成效，非評值。C說出緩解方法屬衛教／知識目標的評值，與本次止痛劑成效無直接對應。D能用助行器下床且無喘，對應的是活動或呼吸目標，與急性疼痛問題不相符。","護理過程 ADPIE（評估—診斷—計畫—執行—評值）中，評值必須「回頭對照原訂目標與措施」看達成度，並以可測量的病人反應為證據。疼痛屬主觀症狀，評值首重病人自述的疼痛量表分數變化（如數字量表NRS 0–10），前後對比才能證明措施有效。判題訣竅：先鎖定護理問題（此題為急性疼痛），評值紀錄的內容主軸必須落在同一問題上，出現活動、知識、呼吸等屬其他問題的成效即可排除。可連結概念：ADPIE、目標導向評值、疼痛評估量表、主觀資料。",[25,28,31,34],{"term":26,"count":27},"護理評值",4,{"term":29,"count":30},"護理過程 ADPIE",3,{"term":32,"count":33},"疼痛量表分數變化",1,{"term":35,"count":33},"目標與措施對應",[37,41,46,51,56,61],{"webId":38,"stem":39,"number":40,"year":10,"session":11},"nurse-108-2-fundamental-nursing-056","有關臨終病人的生理變化，下列敘述何者正確？",56,{"webId":42,"stem":43,"number":44,"year":45,"session":33},"nurse-109-1-fundamental-nursing-072","醫院廢棄物分類中，下列何者非生物醫療廢棄物？",72,109,{"webId":47,"stem":48,"number":49,"year":50,"session":33},"nurse-110-1-fundamental-nursing-006","提供左側下肢乏力但意識清楚之老人安全環境，下列敘述何者正確？",6,110,{"webId":52,"stem":53,"number":54,"year":55,"session":33},"nurse-111-1-fundamental-nursing-044","短腸症病人以全靜脈營養（TPN）方式供給營養，下列敘述何者錯誤？",44,111,{"webId":57,"stem":58,"number":59,"year":60,"session":11},"nurse-112-2-fundamental-nursing-008","承上題，關於林護理師所運用的技巧，下列敘述何者正確？",8,112,{"webId":62,"stem":63,"number":64,"year":65,"session":11},"nurse-113-2-fundamental-nursing-022","記錄導尿管留置病人的輸出入量時，發現 3 小時中尿袋內的尿量為零，應先執行下列何項處置？",22,113,"2026-09-04",1788510705988]