[{"data":1,"prerenderedAt":62},["ShallowReactive",2],{"q-nurse-111-2-medical-surgical-001":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":34,"lastmod":61},"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-111-2-內外科護理學-001","nurse-111-2-medical-surgical-001",111,2,1,"有關頭部外傷病人顱內壓升高的照護，下列何者錯誤？",{"A":14,"B":15,"C":16,"D":17},"避免用力排便、咳嗽、打噴嚏及等長運動","可以使用 Dilantin 預防受傷後抽搐的發生","若病人有鼻漏時應請病人將鼻水擤乾淨","嚴重的顱內壓升高的病人可以使用巴比妥酸鹽（Barbiturate）讓病人鎮靜","C",null,[],"本題考點在顱內壓(ICP)升高的照護原則，要選出錯誤者。C要病人把鼻水擤乾淨是錯誤做法：頭部外傷若出現鼻漏(rhinorrhea)可能是腦脊髓液外漏，用力擤鼻會使顱內壓上升並讓細菌逆行入顱造成腦膜炎，故C錯誤為答案。A正確，用力排便、咳嗽、噴嚏、等長運動都會升高ICP須避免；B正確，Dilantin(phenytoin)可預防外傷後癲癇；D正確，嚴重ICP升高時可用巴比妥酸鹽誘導鎮靜以降低腦部代謝需求。","任何增加胸腔內壓或腹內壓的動作(Valsalva)都會經由靜脈回流受阻而升高ICP。CSF漏的辨識：鼻漏或耳漏可測葡萄糖(CSF含糖、鼻黏液不含)或看暈輪徵象(halo sign)。處理原則為抬高床頭30度、保持頸部正中、避免用力，嚴重時以barbiturate coma降腦代謝。可連結Cushing三聯徵(血壓升、脈搏慢、呼吸不規則)延伸複習。",[24,27,30,32],{"term":25,"count":26},"顱內壓升高",11,{"term":28,"count":29},"腦脊髓液鼻漏",3,{"term":31,"count":10},"巴比妥酸鹽",{"term":33,"count":11},"Valsalva效應",[35,38,43,47,52,57],{"webId":36,"stem":37,"number":10,"year":9,"session":10},"nurse-111-2-medical-surgical-002","有關脊髓損傷後脊髓休克期照護的敘述，下列何者錯誤？",{"webId":39,"stem":40,"number":41,"year":42,"session":11},"nurse-112-1-medical-surgical-018","有關不同關節炎病人的照護措施，下列何者錯誤？",18,112,{"webId":44,"stem":45,"number":46,"year":42,"session":10},"nurse-112-2-medical-surgical-032","有關靜脈曲張之護理指導，下列敘述何者正確？",32,{"webId":48,"stem":49,"number":50,"year":51,"session":10},"nurse-113-2-medical-surgical-050","有關臘腸桿菌（Clostridium botulinum）中毒的預防、症狀與治療之敘述，下列何者正確？",50,113,{"webId":53,"stem":54,"number":55,"year":56,"session":11},"nurse-115-1-medical-surgical-004","有關不同類型腦中風發作之比較，下列敘述何者錯誤？",4,115,{"webId":58,"stem":59,"number":41,"year":60,"session":10},"nurse-106-2-medical-surgical-018","有關軟組織損傷之敘述，下列何者錯誤？",106,"2026-09-04",1788510738257]