[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-109-2-medical-surgical-045":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":33,"lastmod":62},"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-045","nurse-109-2-medical-surgical-045",109,2,45,"有關使用 Braden scale 評估壓傷危險因子和處置之敘述，下列何者正確？",{"A":14,"B":15,"C":16,"D":17},"滿分為 24 分，分數越高表示皮膚風險越大","13 分代表中等危險，需每 2 小時翻身及評估皮膚","依據摩擦力和剪力程度決定是否需使用氣墊床","壓傷危險分級是依據三大層面總和分數做判定","B",null,[],"本題考點是Braden壓傷風險量表的計分與處置，須找出「正確」項。考點在於辨識Braden分數愈「低」風險愈高，13分落在中度危險，須每2小時翻身並評估皮膚，故B正確。A錯在Braden滿分為23分而非24分，且分數越「高」代表皮膚越安全、越低才風險大。C錯在是否使用氣墊床應依「總分」評定的整體風險決定，而非單看摩擦力與剪力一項。D錯在Braden由六大層面組成——感覺知覺、潮濕、活動、移動能力、營養、摩擦力與剪力，並非三大層面總和。故唯一正確為B。","Braden六項各1–4分（摩擦剪力項1–3分），總分6–23：≤9極高危、10–12高危、13–14中危、15–18低危、19–23風險最低，分數愈低愈危險是核心易錯點。翻身頻率通常每2小時、搭配減壓輔具（氣墊床）、皮膚保濕與失禁管理、營養支持。記憶口訣：「感潮動移營摩」六面向；「分低危高」。壓傷分期I–IV加不可分期與深部組織損傷，是另一常考延伸。",[24,27,29,31],{"term":25,"count":26},"Braden壓傷量表",1,{"term":28,"count":26},"六大評估層面",{"term":30,"count":26},"分數越低風險越高",{"term":32,"count":26},"每2小時翻身",[34,38,43,47,52,57],{"webId":35,"stem":36,"number":37,"year":9,"session":10},"nurse-109-2-medical-surgical-046","針對右髖關節嚴重燒傷病人，為維持其關節最大功能之姿位，下列何者正確？",46,{"webId":39,"stem":40,"number":41,"year":42,"session":26},"nurse-110-1-medical-surgical-062","有關尿液檢查目的之敘述，下列何者正確？",62,110,{"webId":44,"stem":45,"number":46,"year":42,"session":10},"nurse-110-2-medical-surgical-076","下列何種休克病人，根據其導因應優先考慮給與水分或血品之輸注？",76,{"webId":48,"stem":49,"number":50,"year":51,"session":26},"nurse-112-1-medical-surgical-034","有關非何杰金氏淋巴瘤預後不佳的因素，下列何者正確？①年齡小於 50 歲 ②身體功能狀態不佳 ③淋巴結外侵犯 ④血紅素值小於 12 g\u002FdL",34,112,{"webId":53,"stem":54,"number":55,"year":56,"session":26},"nurse-113-1-medical-surgical-028","有關氣爆引發四度熱燒傷的健康問題，下列何者較不常發生？",28,113,{"webId":58,"stem":59,"number":60,"year":61,"session":10},"nurse-114-2-medical-surgical-022","正在接受 sorafenib（Nexavar）治療的癌症病人表示：「服藥後手掌和腳掌都出現脫皮、龜裂、刺痛情形，怎麼會這樣呢？」，下列護理指導何者正確？①洗手時不用力搓洗，穿著寬鬆舒適鞋子 ②可塗擦尿素乳膏或凡士林在患部後穿襪就寢 ③外出須戴帽撐傘防曬，但不可以擦防曬乳 ④皮膚乾癢不適時應給與冰敷或熱敷緩解症狀",22,114,"2026-09-04",1788510716697]