[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-110-1-fundamental-nursing-038":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":33,"lastmod":63},"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":11},"nurse-110-1-基本護理學與護理行政-038","nurse-110-1-fundamental-nursing-038",110,1,38,"李先生車禍後因腦挫傷導致顱內壓上升，他的體溫及呼吸可能會出現下列何種反應？",{"A":15,"B":16,"C":17,"D":18},"體溫上升、呼吸過速","體溫上升、呼吸過慢","體溫下降、換氣過度","體溫下降、換氣不足","B",null,[],"本題考點是顱內壓上升時的體溫與呼吸反應。依顱內壓增高的病理生理，壓迫下視丘體溫調節中樞可致中樞性發燒使體溫上升，壓迫腦幹呼吸中樞則使呼吸變慢而深，屬庫欣反應（Cushing reflex）的一環，故選 B 體溫上升、呼吸過慢。A 體溫上升正確但呼吸過速不符，顱內壓高的典型是呼吸變慢或不規則；C、D 皆將體溫描述為下降，與中樞性發燒的方向相反，且換氣過度或不足亦非顱內壓增高的典型呼吸型態。考點在連結「顱內壓上升→中樞受壓→發燒＋呼吸變慢＋血壓上升、脈搏變慢」這組庫欣反應徵象。","庫欣三徵：血壓升高（且脈壓變大）、心搏變慢、呼吸不規則變慢，是顱內壓危象的晚期代償，反映腦部為維持灌注而升壓。體溫因下視丘受壓而中樞性升高。其他顱內壓上升徵象包括意識改變、頭痛、噴射狀嘔吐、瞳孔變化。出現庫欣三徵代表病情惡化、有腦疝之虞，須儘速就醫評估與處置。",[25,27,29,31],{"term":26,"count":11},"顱內壓上升",{"term":28,"count":11},"庫欣反應",{"term":30,"count":11},"中樞性發燒",{"term":32,"count":11},"呼吸中樞受壓",[34,38,43,48,53,58],{"webId":35,"stem":36,"number":37,"year":10,"session":11},"nurse-110-1-fundamental-nursing-039","有關體溫的調節，下列敘述何者錯誤？",39,{"webId":39,"stem":40,"number":41,"year":10,"session":42},"nurse-110-2-fundamental-nursing-055","莊太太有貧血，預做糞便潛血試驗（化學法），下列措施何者錯誤？",55,2,{"webId":44,"stem":45,"number":46,"year":47,"session":11},"nurse-111-1-fundamental-nursing-069","下列那一項溝通屬於不同層級單位人員間的溝通方式？",69,111,{"webId":49,"stem":50,"number":51,"year":52,"session":42},"nurse-112-2-fundamental-nursing-027","有關冷熱應用的注意事項，下列何者最正確？",27,112,{"webId":54,"stem":55,"number":11,"year":56,"session":57},"nurse-113-3-fundamental-nursing-001","競賽前，短跑選手感覺自己的心跳快速、肌肉收縮、口乾、並且全身冒汗，此時該選手正經歷全身適應症候群（general adaptation syndrome）的那個階段？",113,3,{"webId":59,"stem":60,"number":61,"year":62,"session":57},"nurse-114-3-fundamental-nursing-045","病人陳小姐住院期間與母親在病房內大聲爭吵，並出手毆打前來勸架的護理師，緊急處置後通報病人安全通報系統（TPR），此屬於那一類病人安全事件？",45,114,"2026-09-04",1788510720292]