[{"data":1,"prerenderedAt":66},["ShallowReactive",2],{"q-nurse-111-1-psychiatric-community-031":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":35,"lastmod":65},"精神科與社區衛生護理學","psychiatric-community",{"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-精神科與社區衛生護理學-031","nurse-111-1-psychiatric-community-031",111,1,31,"張先生，80 歲，診斷為阿茲海默症，因情緒激動及焦慮而住院。近日因不明原因發燒、咳嗽有痰不舒服，表示要回家，且對陪同住院媳婦不諒解，故出手打了媳婦一巴掌。下列何者護理措施最適當？",{"A":14,"B":15,"C":16,"D":17},"立即給予張先生抗精神病針劑藥物","將張先生帶離現場，協助痰液排出","告知張先生打人是不被允許的","將張先生帶入保護室，予以約束","B",null,[],"本題考點在失智症合併譫妄／攻擊行為的優先護理。依護理過程，須先評估並處理可能引發躁動的生理誘因；張先生近日發燒、咳嗽有痰，感染與缺氧、身體不適極可能誘發譫妄與攻擊，故先將其帶離衝突現場、協助排痰處理生理需求最適當，選 B。考點在於辨識「行為背後的生理誘因優先於約束或說教」。A 立即給抗精神病針劑屬跳過評估的化學約束，非首選；C 對認知受損者道德說教「打人不被允許」無效且徒增對立；D 直接約束、關保護室未先評估誘因，違反最少限制原則。故選 B。","失智者出現急性行為惡化時，須先排除譫妄（delirium）——其常由感染、缺氧、疼痛、脫水、電解質失衡等可逆因素引起。此個案發燒、痰多提示呼吸道感染與可能低血氧，處理生理誘因常使躁動自然緩解。行為處置遵『最少限制原則』：環境調整與去除誘因 → 非藥物安撫 → 必要時才藥物或約束。口訣：『失智突然變兇，先找身體出了什麼狀況（感染、痛、氧）』。",[24,27,29,31,33],{"term":25,"count":26},"最少限制原則",7,{"term":28,"count":10},"失智症合併譫妄",{"term":30,"count":10},"生理誘因評估",{"term":32,"count":10},"感染引發躁動",{"term":34,"count":10},"護理過程優先順序",[36,40,45,50,55,61],{"webId":37,"stem":38,"number":39,"year":9,"session":10},"nurse-111-1-psychiatric-community-032","承上題，張先生懷疑家中地契被媳婦偷。下列何項護理措施最適當？",32,{"webId":41,"stem":42,"number":43,"year":9,"session":44},"nurse-111-2-psychiatric-community-048","下列何項生命統計指標可做為評估國家、社會、經濟和衛生等政策規劃的綜合指標？",48,2,{"webId":46,"stem":47,"number":48,"year":49,"session":10},"nurse-112-1-psychiatric-community-062","有關 A 型肝炎的描述，下列何者正確？",62,112,{"webId":51,"stem":52,"number":53,"year":54,"session":10},"nurse-113-1-psychiatric-community-050","邱先生60歲，已戒菸20年，未曾接受過健康檢查，邱先生可接受全民健保那些免費篩檢？①口腔癌篩檢 ② 大腸癌篩檢 ③攝護腺癌篩檢 ④低劑量電腦斷層檢查",50,113,{"webId":56,"stem":57,"number":58,"year":59,"session":60},"nurse-114-3-psychiatric-community-004","張小弟，診斷注意力不足／過動症，幼兒園大班，上課時喜歡走動，多話，無法遵守教室規定和老師提醒，常跟其他小朋友吵架，下列處置何者最不適當？",4,114,3,{"webId":62,"stem":63,"number":43,"year":64,"session":10},"nurse-106-1-psychiatric-community-048","對處於潛伏期的結核感染者進行痰塗片及痰液培養，下列反應何者正確？",106,"2026-09-04",1788510736440]