[{"data":1,"prerenderedAt":68},["ShallowReactive",2],{"q-nurse-109-2-medical-surgical-029":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":38,"lastmod":67},"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-029","nurse-109-2-medical-surgical-029",109,2,29,"林空服員近日覺得小腿不適，護理師採取下列何項評估其深部靜脈栓塞？",{"A":14,"B":15,"C":16,"D":17},"艾倫試驗（Allen test）","霍曼氏徵象（Homan’s sign）","抬腿試驗（leg raising test）","克尼格氏徵象（Kernig’s sign）","B",null,[],"本題考點在於深部靜脈栓塞的床邊評估方法。霍曼氏徵象是被動背屈足部時引發小腿後側疼痛，用於初步評估深部靜脈栓塞，故選 B。A 艾倫試驗是評估手部橈動脈與尺動脈的側枝循環，於動脈採血或置管前使用，與下肢靜脈無關。C 抬腿試驗多用於評估坐骨神經根壓迫（腰椎神經根刺激），非深部靜脈栓塞。D 克尼格氏徵象為腦膜刺激徵象，與小腿靜脈栓塞無關。故評估深部靜脈栓塞者為霍曼氏徵象。","深部靜脈栓塞好發於長時間不動（久坐長途飛行、術後臥床）、血液高凝與血管內皮受損，即 Virchow 三要素：血流滯緩、高凝狀態、血管壁受損。霍曼氏徵象敏感度與特異度皆不高，臨床已不單獨依賴，確診需搭配 D-dimer、都卜勒超音波。最危險的併發症是血栓脫落造成肺栓塞。護理重點：早期活動、彈性襪、依醫囑抗凝，並衛教勿按摩患肢以免血栓脫落。艾倫試驗（動脈）與霍曼徵象（靜脈）常被並列考，注意區分。",[24,27,30,33,36],{"term":25,"count":26},"肺栓塞",9,{"term":28,"count":29},"深部靜脈栓塞",6,{"term":31,"count":32},"Virchow 三要素",5,{"term":34,"count":35},"霍曼氏徵象",4,{"term":37,"count":10},"艾倫試驗",[39,43,49,53,58,63],{"webId":40,"stem":41,"number":42,"year":9,"session":10},"nurse-109-2-medical-surgical-030","曾先生心臟衰竭住院，住院時出現臉色蒼白、冒冷汗、陣發性夜間呼吸困難及咳出大量帶有血絲的泡沫痰。請問曾先生出現那一種合併症？",30,{"webId":44,"stem":45,"number":46,"year":47,"session":48},"nurse-110-1-medical-surgical-046","有關燒傷病人居家照護的護理指導，下列何者錯誤？",46,110,1,{"webId":50,"stem":51,"number":52,"year":47,"session":10},"nurse-110-2-medical-surgical-060","急性腎衰竭病人血清鉀為 7.2 mEq\u002FL，下列處置何者正確？①靜脈注射中長效胰島素及 5%葡萄糖溶液 ②口服或灌腸給予 Kayexalate ③靜脈注射重碳酸鈉 ④鼓勵多食用香蕉、柳丁",60,{"webId":54,"stem":55,"number":56,"year":57,"session":48},"nurse-112-1-medical-surgical-018","有關不同關節炎病人的照護措施，下列何者錯誤？",18,112,{"webId":59,"stem":60,"number":61,"year":62,"session":48},"nurse-113-1-medical-surgical-012","有關關節炎的敘述，下列何者正確？",12,113,{"webId":64,"stem":65,"number":29,"year":66,"session":10},"nurse-114-2-medical-surgical-006","有關膽囊炎病人的護理評估及照護，下列何者正確？",114,"2026-09-04",1788510716527]