[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-110-1-maternal-pediatric-078":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":33,"lastmod":63},"產兒科護理學","maternal-pediatric",{"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-110-1-產兒科護理學-078","nurse-110-1-maternal-pediatric-078",110,1,78,"小畢，5 歲，因騎腳踏車跌倒，頭撞到地板，出現頭痛、嘔吐的現象，送醫後緊急接受開顱手術，下列有關手術後護理何者不適當？",{"A":14,"B":15,"C":16,"D":17},"密切評估監測意識狀態與生命徵象","觀察有無顱內壓增高症狀，如頭痛、嘔吐、視力模糊等","協助小畢採頭低臀高的姿勢，以促進頭部傷口引流","提供安靜光線柔和的環境，並減少聲光刺激","C",null,[],"本題考點是開顱手術後預防顱內壓上升的護理,要挑出不適當者。考點在於術後應抬高床頭約 15～30 度以促進腦部靜脈回流、降低顱內壓,而頭低臀高會使血液鬱積於顱內、升高顱內壓,故『採頭低臀高姿勢以促進頭部傷口引流』不適當,選 C。選項 A 適當,密切監測意識與生命徵象可及早發現變化;B 適當,觀察頭痛、嘔吐、視力模糊等顱內壓增高徵象;D 適當,安靜柔和的環境可減少刺激與躁動。判斷關鍵在於顱內壓管理須抬高床頭而非頭低。","顱內壓增高的病生理依 Monro-Kellie 假說:顱腔容積固定,腦組織、血液或腦脊髓液任一增加都會推升壓力。護理原則:抬高床頭促靜脈回流、頭頸保持正中避免壓迫頸靜脈、避免用力屏氣與咳嗽、控制發燒與躁動、維持通氣避免二氧化碳滯留造成腦血管擴張。庫欣三徵(血壓升高、脈搏變慢、呼吸不規則)是晚期危險徵象。記憶:『抬頭、正中、少刺激、防屏氣』。可連結瞳孔評估與腦疝脫警訊複習。",[24,27,29,31],{"term":25,"count":26},"抬高床頭促靜脈回流",2,{"term":28,"count":26},"顱內壓增高徵象",{"term":30,"count":26},"開顱術後護理",{"term":32,"count":10},"顱內壓管理",[34,38,43,47,52,58],{"webId":35,"stem":36,"number":37,"year":9,"session":10},"nurse-110-1-maternal-pediatric-079","張小弟，5 個月，因水腦症入院，為預防顱內壓升高，下列護理措施何者不適當？",79,{"webId":39,"stem":40,"number":41,"year":42,"session":10},"nurse-111-1-maternal-pediatric-015","有關剖腹產的手術前護理措施，下列何者最適當？",15,111,{"webId":44,"stem":45,"number":46,"year":42,"session":26},"nurse-111-2-maternal-pediatric-029","下列何項為新生兒晚期飢餓的暗示行為（late hunger cues）？",29,{"webId":48,"stem":49,"number":50,"year":51,"session":26},"nurse-112-2-maternal-pediatric-067","王小弟因血紅素值 4.1 g\u002FdL 須輸血治療，下列敘述何者正確？",67,112,{"webId":53,"stem":54,"number":55,"year":56,"session":57},"nurse-113-3-maternal-pediatric-041","6 歲的小強因不明原因的貧血而入院，欲進行骨髓抽吸術（bone marrow aspiration），下列處置及護理措施何者錯誤？",41,113,3,{"webId":59,"stem":60,"number":61,"year":62,"session":10},"nurse-115-1-maternal-pediatric-035","小敏，8 歲，罹患肌肉失養症（muscular dystrophy），呼吸急促且有喘鳴聲，經門診入院求治，以家庭為中心的護理措施，下列敘述何者最不適當？",35,115,"2026-09-04",1788510722336]