[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-110-2-medical-surgical-037":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":35,"lastmod":64},"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-110-2-內外科護理學-037","nurse-110-2-medical-surgical-037",110,2,37,"病人接受化學治療後血小板數值為 10,000 cells\u002Fmm，下列何者為護理評估重點？",{"A":14,"B":15,"C":16,"D":17},"意識狀態","體溫變化","腸蠕動音","皮膚飽和度","A",null,[],"本題考點在於化學治療後嚴重血小板低下的護理評估重點。血小板數值降至10,000 cells\u002Fmm³屬極重度血小板低下，自發性出血風險高，其中最危急的是顱內出血，因此以觀察「意識狀態」的變化來及早偵測顱內出血最為關鍵，故A正確。體溫變化(B)反映的是感染風險，與白血球或中性球低下較相關，非血小板議題。腸蠕動音(C)屬腸胃功能評估，與出血風險無直接關聯。皮膚飽和度(D)敘述不明確且非血小板低下的核心監測指標。故正確為意識狀態A。","血小板\u003C20,000有自發性出血風險、\u003C10,000極高危，最致命為顱內與消化道出血，故監測意識、瞳孔、頭痛、嘔吐等神經徵象。護理措施：避免侵入性操作與肌肉注射、用軟毛牙刷與電動刮鬍刀、預防便祕免用力、避免阿斯匹靈。對比中性球低下(感染風險)才重點監測體溫。記憶口訣「血小板低看出血、中性球低看發燒」。可連結概念：骨髓抑制、出血徵象、感染防護。",[24,27,30,33],{"term":25,"count":26},"骨髓抑制",8,{"term":28,"count":29},"血小板低下",3,{"term":31,"count":32},"顱內出血風險",1,{"term":34,"count":32},"意識狀態評估",[36,40,45,49,54,59],{"webId":37,"stem":38,"number":39,"year":9,"session":10},"nurse-110-2-medical-surgical-038","有關何杰金氏淋巴瘤的敘述，下列何者錯誤？",38,{"webId":41,"stem":42,"number":43,"year":44,"session":32},"nurse-111-1-medical-surgical-054","病人行氣管內插管後聽診呼吸音時，發現左側肺部呼吸音減弱但右側正常，下列何者為導致此情形最可能的原因？",54,111,{"webId":46,"stem":47,"number":48,"year":44,"session":10},"nurse-111-2-medical-surgical-068","有關甲狀腺風暴的敘述，下列何者錯誤？",68,{"webId":50,"stem":51,"number":52,"year":53,"session":29},"nurse-112-3-medical-surgical-026","病人於化學治療後抽血報告顯示 WBC 3,000\u002FμL、Platelet 30,000\u002FμL、Hb 12g\u002FdL，下列照護措施何者最適宜？",26,112,{"webId":55,"stem":56,"number":57,"year":58,"session":32},"nurse-114-1-medical-surgical-030","有關後天免疫缺乏症候群（AIDS）臨床表徵之敘述，下列何者錯誤？",30,114,{"webId":60,"stem":61,"number":62,"year":63,"session":10},"nurse-115-2-medical-surgical-024","一位癌症病人檢查及評估結果如下：血壓 105\u002F65 mmHg，呼吸 20 次／分，心電圖顯示正常竇性心律，鉀離子 4.1 mmol\u002FL，尿酸 5.5 mg\u002FdL，血鈣 9.2 mg\u002FdL，蹠反射強直，無水腫症狀。病人最可能罹患下列何種腫瘤急症？",24,115,"2026-09-04",1788510729125]