[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-110-1-maternal-pediatric-079":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-079","nurse-110-1-maternal-pediatric-079",110,1,79,"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？",{"A":14,"B":15,"C":16,"D":17},"密切觀察有無囟門鼓脹或噴射狀嘔吐現象","抬高床頭 30～45 度，以降低腦內壓","術後每 2 小時協助叩擊與抽痰，以預防吸入性肺炎","給予安撫奶嘴以減少哭泣不安","C",null,[],"本題考點是水腦症病童預防顱內壓升高的護理,要挑出不適當者。考點在於叩擊與抽痰屬強烈刺激,會引發咳嗽與屏氣而使顱內壓上升,不宜作為常規每 2 小時例行執行,故選 C。選項 A 適當,囟門鼓脹與噴射狀嘔吐是嬰兒顱內壓增高的重要徵象,須密切觀察;B 適當,抬高床頭 30～45 度有助靜脈回流、降低腦內壓;D 適當,給安撫奶嘴減少哭鬧可避免因用力屏氣造成顱內壓上升。判斷關鍵在於避免會誘發顱內壓升高的刺激性操作。","嬰兒顱骨縫尚未閉合,顱內壓增高早期可見囟門膨隆緊繃、頭圍增大、落日眼徵、噴射狀嘔吐與高音尖叫。護理以降低與避免升高顱內壓為主軸:抬高床頭、減少哭鬧與刺激、輕柔操作、集中護理減少反覆干擾。抽痰、叩擊會誘發咳嗽屏氣升高顱內壓,僅在確有呼吸道分泌物需求時謹慎為之,並非每 2 小時常規執行。腦室腹腔引流術後要觀察引流功能與感染徵象。記憶:『囟門凸、落日眼、噴射吐;護理避刺激、抬床頭』。可連結引流管照護複習。",[24,27,29,31],{"term":25,"count":26},"水腦症",2,{"term":28,"count":10},"顱內壓升高預防",{"term":30,"count":10},"抽痰叩擊刺激",{"term":32,"count":10},"囟門與噴射狀嘔吐",[34,38,43,47,52,58],{"webId":35,"stem":36,"number":37,"year":9,"session":10},"nurse-110-1-maternal-pediatric-080","有關兒童腦性麻痺的型態及表徵，下列敘述何者不適當？",80,{"webId":39,"stem":40,"number":41,"year":42,"session":10},"nurse-111-1-maternal-pediatric-016","下列何者為枕後位（OP）第一、二產程延長的主要機轉？",16,111,{"webId":44,"stem":45,"number":46,"year":42,"session":26},"nurse-111-2-maternal-pediatric-030","下列何項不是新生兒於睡眠活動週期中「安靜清醒期」（quiet alert state）的行為表徵？",30,{"webId":48,"stem":49,"number":50,"year":51,"session":26},"nurse-112-2-maternal-pediatric-068","有關血友病（Hemophilia）兒童的居家照護指導，下列敘述何者最為正確？",68,112,{"webId":53,"stem":54,"number":55,"year":56,"session":57},"nurse-113-3-maternal-pediatric-042","有關預防腫瘤溶解症候群（tumor lysis syndrome）所進行的相關處置，下列敘述何者錯誤？",42,113,3,{"webId":59,"stem":60,"number":61,"year":62,"session":10},"nurse-115-1-maternal-pediatric-036","瀕死兒童出現肌肉緊張力降低，下列敘述何者最不適當？",36,115,"2026-09-04",1788510722351]