[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-111-1-maternal-pediatric-080":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":36,"lastmod":62},"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-111-1-產兒科護理學-080","nurse-111-1-maternal-pediatric-080",111,1,80,"張小妹，10 歲，罹患腦膜炎，出現顱內壓增高（Increased intracranial pressure, IICP），下列護理措施何者不適當？",{"A":14,"B":15,"C":16,"D":17},"監測有無便秘情形","監測有無噴射式嘔吐、認知改變","避免執行頭低腳高的姿位引流","執行背部扣擊或抽痰，以利呼吸道通暢","D",null,[],"本題考點為腦膜炎併發顱內壓增高（IICP）的護理措施，題目要選「不適當」者。IICP 照護原則是一切避免使腦部血流或腦脊髓液回流受阻、避免任何升高胸腹腔壓力的動作。依此原則，D 執行背部扣擊或抽痰會刺激咳嗽、憋氣並升高胸腔壓，使顱內壓進一步上升，屬不適當，故選 D。A 正確，需監測便秘，因用力解便（Valsalva 動作）會升高顱內壓應予預防。B 正確，噴射式嘔吐與認知改變是 IICP 的典型徵象需嚴密監測。C 正確，應避免頭低腳高姿位引流，以防腦部靜脈回流受阻。","顱內壓的調控依 Monro-Kellie 假說：顱腔容積固定，腦組織、血液、腦脊髓液三者總和恆定，任一增加須由另二者代償，代償耗盡後壓力急遽上升。故護理策略圍繞「促進靜脈回流、避免升壓」：床頭抬高約 30 度、頭頸維持中線、避免髖屈曲、減少刺激與集中護理、預防便秘與咳嗽憋氣。抽痰前後過度換氣、單次抽吸時間過長皆會誘發 IICP 高峰。庫欣三徵（血壓升高、脈搏變慢、呼吸不規則）為晚期危險訊號。記憶重點：任何讓病人「用力、憋氣、頭低」的動作在 IICP 都是禁忌。",[24,27,29,32,34],{"term":25,"count":26},"顱內壓增高",3,{"term":28,"count":26},"庫欣三徵",{"term":30,"count":31},"Monro-Kellie 假說",2,{"term":33,"count":10},"Valsalva 動作",{"term":35,"count":10},"抽痰升壓",[37,40,45,49,54,58],{"webId":38,"stem":39,"number":10,"year":9,"session":31},"nurse-111-2-maternal-pediatric-001","有關懷孕期正常內分泌變化的敘述，下列何者正確？",{"webId":41,"stem":42,"number":43,"year":44,"session":10},"nurse-112-1-maternal-pediatric-017","有關胎心音監測的敘述，下列何者正確？",17,112,{"webId":46,"stem":47,"number":48,"year":44,"session":31},"nurse-112-2-maternal-pediatric-031","江女士為百貨公司化妝品銷貨員，因長期久站，懷孕前左腿即有明顯的靜脈曲張情形，產後會陰傷口腫脹疼痛而不願下床活動，產後第三天她試著下床步行，當她站立伸直左右小腿時，左小腿會感覺疼痛，觸摸也會覺得壓痛。依據上述情況，下列何項判斷及處置較適當？",31,{"webId":50,"stem":51,"number":52,"year":53,"session":31},"nurse-113-2-maternal-pediatric-049","有關嬰幼兒呼吸系統解剖生理特徵，下列何者正確？",49,113,{"webId":55,"stem":56,"number":26,"year":57,"session":10},"nurse-115-1-maternal-pediatric-003","張女士，懷孕期頻繁噁心嘔吐的情況很不舒服，下列護理指導何者較不合適？",115,{"webId":59,"stem":60,"number":43,"year":61,"session":31},"nurse-106-2-maternal-pediatric-017","胎兒預估體重 3200 公克，胎位（Fetal Position）為枕後位（OP），下列敘述何者正確？①子宮收縮力比較弱 ②第一產程時間較長 ③先露部下降較快 ④子宮頸擴張較慢",106,"2026-09-04",1788510736104]