[{"data":1,"prerenderedAt":61},["ShallowReactive",2],{"q-nurse-111-1-medical-surgical-002":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":32,"lastmod":60},"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":10},"nurse-111-1-內外科護理學-002","nurse-111-1-medical-surgical-002",111,1,2,"有關病人已出現顱內壓升高的護理處置，下列敘述何者錯誤？",{"A":14,"B":15,"C":16,"D":17},"保持病人的頭頸在正中位置","抬高床頭 30 度","將抽痰、翻身拍背、擦澡等活動都集中一次完成","應注意體溫的控制及維持排便正常","C",null,[],"本題考點在於顱內壓升高(IICP)的護理處置,並找出敘述錯誤者。依顱內壓調節原理,護理活動(如抽痰、翻身拍背、擦澡)會短暫升高顱內壓,故應「分散、間隔進行並穿插休息」,讓顱內壓有回復時間;若將這些活動「集中一次完成」,會使刺激疊加而造成顱內壓持續飆高,反而有害,故 C 為錯誤處置,選 C。A 保持頭頸正中位可避免頸靜脈受壓、利於腦部靜脈回流,正確;B 抬高床頭約 30 度促進靜脈回流以降低顱內壓,正確;D 控制體溫(避免發燒增加腦代謝)與維持排便通暢(避免用力解便引起 Valsalva 動作升壓),皆正確。因此集中護理活動的敘述錯誤。","顱內壓升高照護核心是「減少任何會增加顱內容積或阻礙靜脈回流的因素」。護理活動應分散(spacing)而非群聚(clustering),因連續刺激會使 ICP 累加無法回落;抽痰前給氧、每次不超過 10~15 秒亦為要點。其他降壓措施:床頭抬高 30 度、頭頸正中避免屈曲\u002F旋轉、避免髖部過度屈曲、控制發燒與疼痛、預防便秘與咳嗽(降低胸腹內壓與 Valsalva)、維持正常血氧與避免高碳酸血症(CO₂ 上升會腦血管擴張升壓)。記憶:IICP 護理=分散刺激、促進回流、避免升壓動作。延伸連結庫欣氏三徵(血壓升高、脈搏變慢、呼吸型態改變)為晚期警訊。",[24,26,28,30],{"term":25,"count":10},"顱內壓升高護理",{"term":27,"count":10},"護理活動應分散進行",{"term":29,"count":10},"床頭抬高促靜脈回流",{"term":31,"count":10},"避免 Valsalva 動作",[33,37,41,46,51,56],{"webId":34,"stem":35,"number":36,"year":9,"session":10},"nurse-111-1-medical-surgical-003","有關腰椎椎間盤突出的敘述，下列何者錯誤？",3,{"webId":38,"stem":39,"number":40,"year":9,"session":11},"nurse-111-2-medical-surgical-019","王先生接受右側全髖關節置換術後出現胸痛、呼吸短促、皮膚蒼白、冰冷。下列何者是王先生最可能產生的術後合併症？",19,{"webId":42,"stem":43,"number":44,"year":45,"session":10},"nurse-112-1-medical-surgical-033","接受同步化學放射治療（CCRT）的病人，其抽血報告顯示 WBC 3000\u002FμL、seg 20%、band 5%、 monocyte 12%、Hb 10.5 g\u002FdL、platelet 50000\u002FμL，下列敘述何者錯誤？",33,112,{"webId":47,"stem":48,"number":49,"year":50,"session":10},"nurse-113-1-medical-surgical-021","針對接受trastuzumab（Herceptin®）治療的癌症病人之護理，下列何者正確？①靜脈滴注給藥 ②空腹口服給藥 ③監測丘疹、手足症候群 ④監測心臟功能",21,113,{"webId":52,"stem":53,"number":54,"year":55,"session":11},"nurse-114-2-medical-surgical-025","王先生接受輸血治療過程中發生乾咳、血壓上升、嚴重呼吸困難等情形，下列何者為其最有可能發生的輸血不良反應？",25,114,{"webId":57,"stem":58,"number":40,"year":59,"session":10},"nurse-106-1-medical-surgical-019","評估膝關節內是否有少量液體積存之方法，下列何者正確？",106,"2026-09-04",1788510734219]