[{"data":1,"prerenderedAt":61},["ShallowReactive",2],{"q-nurse-108-2-medical-surgical-004":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":32,"lastmod":60},"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-108-2-內外科護理學-004","nurse-108-2-medical-surgical-004",108,2,4,"顱內壓升高（IICP）的臨床表徵，下列何者正確？",{"A":14,"B":15,"C":16,"D":17},"心跳增加","血壓下降","脈壓變寬","視神經萎縮","C",null,[],"本題考點是顱內壓升高（IICP）的典型臨床表徵。依 Cushing 反應，顱內壓升高壓迫腦幹時，身體代償使血壓上升（收縮壓升高但舒張壓相對不變），造成脈壓變寬，故選 C。選項 A「心跳增加」錯誤，Cushing 反應呈現的是心搏過緩（bradycardia），非心跳加快；選項 B「血壓下降」錯誤，典型為血壓上升；選項 D「視神經萎縮」錯誤，IICP 呈現的是視乳突水腫（papilledema），萎縮是慢性長期結果而非急性表徵。考點在於辨識 Cushing 三徵中的脈壓變寬。","Cushing 三徵（Cushing's triad）是顱內壓升高的晚期危險訊號：收縮壓升高致脈壓變寬、心搏過緩、呼吸型態不規則。機轉為腦部灌流受威脅時，交感神經升壓以維持腦血流，壓力感受器再反射性地減慢心跳。其他 IICP 表徵含意識程度下降（最早、最敏感）、頭痛、噴射狀嘔吐、視乳突水腫、瞳孔變化。記憶口訣：血壓『上』、脈壓『寬』、心跳『慢』、呼吸『亂』。可連結門羅—凱利假說與腦灌流壓（CPP = MAP − ICP）——ICP 上升會壓縮 CPP，身體只好拉高 MAP 代償。",[24,27,29,30],{"term":25,"count":26},"顱內壓升高 IICP",1,{"term":28,"count":26},"Cushing 三徵",{"term":16,"count":26},{"term":31,"count":26},"視乳突水腫",[33,37,42,46,51,56],{"webId":34,"stem":35,"number":36,"year":9,"session":10},"nurse-108-2-medical-surgical-005","有關照護 HIV 感染者及共同生活者之護理指導，下列何者正確？",5,{"webId":38,"stem":39,"number":40,"year":41,"session":26},"nurse-109-1-medical-surgical-021","有關美尼爾氏症候群的敘述，下列何者錯誤？",21,109,{"webId":43,"stem":44,"number":45,"year":41,"session":10},"nurse-109-2-medical-surgical-035","王先生入院接受心導管檢查，此次檢查穿刺左側橈動脈，下列護理處置何者錯誤？",35,{"webId":47,"stem":48,"number":49,"year":50,"session":10},"nurse-110-2-medical-surgical-073","王先生，58 歲，罹患糖尿病 2 年，藉由口服抗血糖藥物、飲食與運動控制血糖，今日在家昏倒救護車送入急診，心跳 118 次／分，血壓 85\u002F50 mmHg，呼吸速率 20 次／分，血糖為 650 mg\u002FdL。下列何者為最可能之診斷？",73,110,{"webId":52,"stem":53,"number":54,"year":55,"session":26},"nurse-112-1-medical-surgical-037","周女士，52 歲，本身有高血壓及乳癌家族史，有抽菸，在一次回診時表示自己年紀越來越大，很擔心會跟媽媽一樣罹癌，下列建議何者錯誤？",37,112,{"webId":57,"stem":58,"number":40,"year":59,"session":26},"nurse-113-1-medical-surgical-021","針對接受trastuzumab（Herceptin®）治療的癌症病人之護理，下列何者正確？①靜脈滴注給藥 ②空腹口服給藥 ③監測丘疹、手足症候群 ④監測心臟功能",113,"2026-09-04",1788510706217]