[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-109-1-maternal-pediatric-052":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":32,"lastmod":62},"產兒科護理學","maternal-pediatric",{"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":10},"nurse-109-1-產兒科護理學-052","nurse-109-1-maternal-pediatric-052",109,1,52,"丁丁，2 歲，診斷為水腦，並接受腦室－腹膜分流術（V-P shunt），現已術後第 5 天，今早丁丁哭鬧不喝奶，測得體溫達 38.2℃、血壓為 100\u002F60 mmHg，有關護理評估，下列何者需優先執行？",{"A":14,"B":15,"C":16,"D":17},"疼痛評估","意識評估","感染評估","營養評估","C",null,[],"本題考點在於腦室-腹膜分流術(V-P shunt)術後併發症的優先評估,重點在於辨識分流管感染:丁丁術後第5天哭鬧不喝奶、體溫達38.2℃,發燒是V-P shunt術後最需警覺的分流管感染徵象,故護理評估應優先執行感染評估,選C。分流管感染多發生於術後1至2個月內,可導致腦膜炎與分流失效,故發燒須立即評估。A疼痛評估雖需進行,但發燒優先指向感染。B意識評估重要於分流阻塞或顱內壓升高時,但此情境以發燒為主要異常。D營養評估屬長期照護面向,非急性發燒時的優先項目。因此優先執行者為C感染評估。","V-P shunt兩大併發症:阻塞(顱內壓升高徵象——嘔吐、囟門膨出、意識改變、落日眼)與感染(發燒、傷口紅腫、腦膜炎徵象、餵食差),感染好發於置管後早期。本題以發燒為突出線索,依線索導向優先評估感染。護理監測連結:記錄體溫趨勢、觀察分流路徑皮膚、留意顱內壓變化與囟門張力。記憶要點:「shunt術後發燒先想感染,意識\u002F嘔吐先想阻塞」。可連結水腦症病生理、顱內壓升高徵象與分流管照護衛教一併複習。",[24,26,28,30],{"term":25,"count":10},"V-P shunt 併發症",{"term":27,"count":10},"分流管感染",{"term":29,"count":10},"術後發燒優先評估",{"term":31,"count":10},"顱內壓升高辨析",[33,37,42,47,52,57],{"webId":34,"stem":35,"number":36,"year":9,"session":10},"nurse-109-1-maternal-pediatric-053","小明，3 歲，被機車撞倒，頭部受傷，有關腦壓增高的早期臨床表徵，不包括下列何者？",53,{"webId":38,"stem":39,"number":40,"year":9,"session":41},"nurse-109-2-maternal-pediatric-069","小明 3 歲，罹患急性淋巴性白血病，有關接受誘導期化學治療的敘述，下列何者錯誤？",69,2,{"webId":43,"stem":44,"number":45,"year":46,"session":41},"nurse-110-2-maternal-pediatric-003","有關第二孕期母血唐氏症四指標（quadruple test）之檢測項目，下列何者錯誤？",3,110,{"webId":48,"stem":49,"number":50,"year":51,"session":41},"nurse-111-2-maternal-pediatric-041","依據美國燒傷協會有關兒童重度燒燙傷程度的分類，下列敘述何者正確？",41,111,{"webId":53,"stem":54,"number":55,"year":56,"session":45},"nurse-112-3-maternal-pediatric-005","有關羊膜穿刺術（amniocentesis）的檢查時機及情況，下列敘述何者正確？",5,112,{"webId":58,"stem":59,"number":60,"year":61,"session":45},"nurse-113-3-maternal-pediatric-049","10 歲的曉華罹患頑固型癲癇，醫生建議以生酮飲食治療，下列何者正確？",49,113,"2026-09-04",1788510713612]