[{"data":1,"prerenderedAt":66},["ShallowReactive",2],{"q-nurse-110-1-medical-surgical-028":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":35,"lastmod":65},"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-110-1-內外科護理學-028","nurse-110-1-medical-surgical-028",110,1,28,"下列何者最可能為腹主動脈瘤病人的病史或身體檢查與評估的結果？",{"A":14,"B":15,"C":16,"D":17},"出現腹部腫塊與血壓上升等現象","聽診腹部，會聽到舒張期血管嘈音","主訴腹部有心跳搏動感","當疼痛轉移至下背部，表示症狀緩解","C",null,[],"本題考點為腹主動脈瘤（AAA）的典型評估發現。考點在於動脈瘤是主動脈局部異常擴張且具搏動性，故病人常在臍周摸到並主訴腹部有隨心跳的搏動感，選 C。A 錯在血壓，AAA 本身不必然使血壓上升，若瘤體破裂反而會因大量出血而血壓下降。B 錯在雜音時相，聽診腹部聽到的是收縮期血管雜音（bruit），非舒張期。D 錯在疼痛意義，疼痛轉移至下背部常代表瘤體擴大或即將破裂的危險徵象，而非症狀緩解。","AAA 危象辨識：多數無症狀，體檢偶見臍周搏動性腫塊、收縮期 bruit。破裂三徵：突發劇烈腹／背痛、搏動性腫塊、低血壓，屬外科急症。護理重點在於避免用力觸診以免誘發破裂。對比：搏動性（AAA）vs 非搏動性腫塊。記憶：背痛加劇＝警報升級（擴大／滲漏／破裂），不是好轉。動脈瘤 >5.5 cm 或快速增大常需手術修補。",[24,27,29,31,33],{"term":25,"count":26},"腹主動脈瘤",2,{"term":28,"count":10},"搏動性腫塊",{"term":30,"count":10},"血管雜音",{"term":32,"count":10},"動脈瘤破裂",{"term":34,"count":10},"下背痛",[36,40,44,49,54,59],{"webId":37,"stem":38,"number":39,"year":9,"session":10},"nurse-110-1-medical-surgical-029","有關長時間靜脈注射抗生素引發靜脈炎的護理措施，下列何者錯誤？",29,{"webId":41,"stem":42,"number":43,"year":9,"session":26},"nurse-110-2-medical-surgical-045","有關傷口敷料的敘述，下列何者正確？",45,{"webId":45,"stem":46,"number":47,"year":48,"session":10},"nurse-111-1-medical-surgical-059","胸腔手術後病人進行深呼吸運動之主要成效，下列何者正確？",59,111,{"webId":50,"stem":51,"number":52,"year":53,"session":26},"nurse-112-2-medical-surgical-017","有關骨質疏鬆症護理指導之敘述，下列何者錯誤？",17,112,{"webId":55,"stem":56,"number":57,"year":58,"session":26},"nurse-113-2-medical-surgical-041","同時會出現在腎病症候群與急性腎絲球腎炎之臨床表徵，下列何者正確？①水腫 ②高血脂 ③蛋白尿 ④血尿",41,113,{"webId":60,"stem":61,"number":62,"year":63,"session":64},"nurse-114-3-medical-surgical-035","有關肺心症病人呼吸道清除功能失效問題之護理處置，下列敘述何者最不適當？",35,114,3,"2026-09-04",1788510721017]