[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-109-2-medical-surgical-015":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":37,"lastmod":64},"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-109-2-內外科護理學-015","nurse-109-2-medical-surgical-015",109,2,15,"有關腹膜炎病人身體評估之發現，下列何者正確？①腹痛輻射至背部或肩膀 ②腹部肌肉僵硬如木板 ③觸診腹部時出現壓痛及反彈痛 ④腸蠕動音增強",{"A":14,"B":15,"C":16,"D":17},"①③","①④","②③","②④","C",null,[],"本題考點在於腹膜炎的身體評估發現，屬組合選擇題。腹膜受刺激時腹肌反射性強直，觸診如木板般僵硬（②，board-like rigidity）；同時因壁層腹膜發炎而出現明顯壓痛與反彈痛（③，rebound tenderness），兩者為腹膜炎的標誌性徵象，故選 C（②③）。①腹痛輻射至背部或肩膀較符合胰臟炎或膽道疾病，非腹膜炎特徵。④腸蠕動音的變化在腹膜炎應為減弱或消失（因發炎導致麻痺性腸阻塞），而非增強，故④敘述相反。因此正確組合為②③。","腹膜炎的核心是「腹膜刺激徵象」：肌肉防衛性強直（guarding）、反彈痛、壓痛，病人常屈膝仰臥不敢移動以減少腹膜牽扯。壁層腹膜富含體神經，故疼痛定位清楚且劇烈；相對地臟層腹膜疼痛則模糊。發炎會引發反射性腸麻痺，故腸蠕動音減弱至消失（與腸阻塞早期蠕動音亢進不同）。腹痛輻射至肩背多提示膈肌刺激或胰膽疾病。臨床可伴發燒、白血球升高與敗血症風險，屬急症。",[24,27,29,32,35],{"term":25,"count":26},"腹膜刺激徵象",4,{"term":28,"count":26},"麻痺性腸阻塞",{"term":30,"count":31},"腹膜炎",3,{"term":33,"count":34},"板狀腹",1,{"term":36,"count":34},"反彈痛",[38,42,47,51,55,59],{"webId":39,"stem":40,"number":41,"year":9,"session":10},"nurse-109-2-medical-surgical-016","病人主訴「餓的時候疼痛，常常半夜痛醒」，下列何者為其最大可能之診斷？",16,{"webId":43,"stem":44,"number":45,"year":46,"session":34},"nurse-110-1-medical-surgical-032","有關心臟血管系統的診斷檢查結果，下列敘述何者正確？",32,110,{"webId":48,"stem":49,"number":50,"year":46,"session":10},"nurse-110-2-medical-surgical-046","有關蜂窩性組織炎病人的護理措施，下列何者錯誤？",46,{"webId":52,"stem":53,"number":26,"year":54,"session":34},"nurse-112-1-medical-surgical-004","有關腦腫瘤病人術後發生尿崩症，下列敘述何者正確？",112,{"webId":56,"stem":57,"number":58,"year":54,"session":31},"nurse-112-3-medical-surgical-048","有關自動體外心臟電擊去顫器（AED）的操作敘述，下列何者錯誤？",48,{"webId":60,"stem":61,"number":62,"year":63,"session":34},"nurse-114-1-medical-surgical-042","有關糖尿病酮酸中毒（DKA）之處置，下列何者正確？①建立靜脈輸液，由低劑量胰島素開始給與 ②最初2小時，給與0.45％生理食鹽水維持電解質平衡         ③等尿液排出量恢復正常，應補充鉀離子 ④血液pH值>7.1時，則與以重碳酸鈉（NaHCO 3）",42,114,"2026-09-04",1788510716381]