[{"data":1,"prerenderedAt":66},["ShallowReactive",2],{"q-nurse-109-2-fundamental-nursing-055":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":35,"lastmod":65},"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-109-2-基本護理學與護理行政-055","nurse-109-2-fundamental-nursing-055",109,2,55,"有關臨終病人生理變化之敘述，下列何者錯誤？",{"A":15,"B":16,"C":17,"D":18},"肌肉張力減低和貧血，出現希氏面容（facies Hippocratica）","呼吸急促、鼻翼搧動及張口呼吸","腸道蠕動快速，易腹瀉及口水分泌多","四肢脈搏呈現絲脈，心尖搏動最後消失","C",null,[],"本題考點是臨終病人的生理變化，須辨識錯誤敘述。臨終時自主神經與循環功能衰退，腸胃蠕動「減慢」、分泌物減少，故C說「腸道蠕動快速、易腹瀉及口水分泌多」與實際相反，為錯誤敘述，選C。A肌肉張力下降合併循環衰竭出現希氏面容（facies Hippocratica，兩頰凹陷、鼻尖銳）正確。B瀕死呼吸型態改變、鼻翼搧動、張口呼吸正確。D周邊循環變差呈絲脈，心尖搏動因心臟最後停止而最後消失，正確。故錯誤者為C。","延伸：臨終腸胃道蠕動減緩易致腹脹、便秘而非腹瀉；唾液與吞嚥反射減弱使分泌物滯留咽喉，形成瀕死嘎嘎音（death rattle）。希氏面容反映脫水與循環衰竭。循環由末梢向中心衰竭，故脈搏先弱於四肢、心音最後消失。記憶：臨終「腸胃慢、分泌少、循環由外向內收」。可連結：death rattle處置、瀕死徵象評估。",[25,28,30,33],{"term":26,"count":27},"臨終生理變化",5,{"term":29,"count":11},"希氏面容",{"term":31,"count":32},"絲脈",1,{"term":34,"count":32},"腸胃蠕動減緩",[36,40,45,50,55,60],{"webId":37,"stem":38,"number":39,"year":10,"session":11},"nurse-109-2-fundamental-nursing-056","接受安寧居家照護的臨終病人，其意識不清，且出現瀕死嘎嘎音（death rattle）時之處置，下列敘述何者適當？",56,{"webId":41,"stem":42,"number":43,"year":44,"session":32},"nurse-110-1-fundamental-nursing-072","在單位中若大部分的護理同仁為資淺且臨床能力較不足，但仍有意願完成工作，基於情境領導理論，此時護理長宜採取下列何項領導行為？",72,110,{"webId":46,"stem":47,"number":48,"year":49,"session":32},"nurse-111-1-fundamental-nursing-006","下列何者不屬於內科無菌的技術？",6,111,{"webId":51,"stem":52,"number":53,"year":54,"session":32},"nurse-112-1-fundamental-nursing-044","有關死亡後遺體的變化，下列敘述何者正確？",44,112,{"webId":56,"stem":57,"number":58,"year":59,"session":32},"nurse-113-1-fundamental-nursing-038","顧力克（Luther Gulick）以POSDCoRB七個縮寫字說明行政的內涵，請問下列敘述何者正確？",38,113,{"webId":61,"stem":62,"number":63,"year":64,"session":11},"nurse-114-2-fundamental-nursing-032","有關出院計畫的敘述，下列何者正確？①以病人為中心來制定計畫內容，以確保持續性照護 ②於醫師開立出院醫囑當天開始執行 ③需避免病人或家屬直接執行傷口照護，以防再度感染 ④由病人、照護者、醫師、護理師及其他醫療團隊共同擬訂",32,114,"2026-09-04",1788510715970]