[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-111-2-psychiatric-community-031":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":33,"lastmod":62},"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-111-2-精神科與社區衛生護理學-031","nurse-111-2-psychiatric-community-031",111,2,31,"針對譫妄病人的護理措施，下列何者正確？",{"A":14,"B":15,"C":16,"D":17},"限制飲水，以減少尿失禁情形","環境布置多元豐富，以增加感官刺激","出現睡眠紊亂時，應優先給予安眠藥物幫助入睡","溝通時應簡短扼要，重複告知人事時地物的訊息","D",null,[],"本題考點是譫妄病人的護理措施。依譫妄照護的現實導向(reality orientation)原則,病人有注意力與定向感障礙且意識狀態波動,溝通須簡短扼要,並反覆提供人、事、時、地、物的訊息(如時鐘、日曆、熟悉物品)以強化定向感,故 D 正確。A 錯在限制飲水可能造成脫水與電解質失衡,而脫水正是譫妄的常見誘發因子,反而加重病情。B 錯在譫妄病人對刺激的處理能力下降,環境應簡單、安靜、光線適當,多元豐富的布置形成過度刺激,惡化混亂。C 錯在安眠藥物(尤其苯二氮平類)可能加深意識混亂、加重譫妄,睡眠紊亂應優先採非藥物措施(日夜節律調整、白天活動)。","譫妄三大臨床特徵:急性發作、意識混亂程度呈波動性(常見日落症候群,傍晚惡化)、注意力不集中,與失智症「慢性、漸進、意識清楚」形成對比,是必考鑑別。護理核心「找原因、穩環境、保安全」:治療根本誘因(感染、缺氧、電解質異常、藥物)、維持環境一致與適度光線、夜間留小燈、安排熟悉家屬陪伴、避免頻繁更換照護者。藥物僅在激躁危及安全時考慮低劑量抗精神病藥,苯二氮平類原則上避免(酒精戒斷譫妄除外)。",[24,27,29,31],{"term":25,"count":26},"譫妄護理措施",1,{"term":28,"count":26},"現實導向療法",{"term":30,"count":26},"譫妄誘發因子",{"term":32,"count":26},"譫妄與失智鑑別",[34,38,43,47,53,58],{"webId":35,"stem":36,"number":37,"year":9,"session":10},"nurse-111-2-psychiatric-community-032","有關老年精神病人的藥物治療，下列敘述何者最適當？",32,{"webId":39,"stem":40,"number":41,"year":42,"session":26},"nurse-112-1-psychiatric-community-048","下列那一階段的疾病自然史，最能透過篩檢早期發現身體病理變化？",48,112,{"webId":44,"stem":45,"number":46,"year":42,"session":10},"nurse-112-2-psychiatric-community-062","有關自來水淨水過程，下列何種消毒法最為廣泛且價格最便宜？",62,{"webId":48,"stem":49,"number":50,"year":51,"session":52},"nurse-113-3-psychiatric-community-030","為降低感染 COVID-19 的風險而施打 COVID-19 疫苗，是屬於預防概念的何種層級？",30,113,3,{"webId":54,"stem":55,"number":56,"year":57,"session":26},"nurse-115-1-psychiatric-community-034","依據三段五級概念，下列那一項屬於第一級的預防措施？",34,115,{"webId":59,"stem":60,"number":41,"year":61,"session":10},"nurse-106-2-psychiatric-community-048","造成家庭暴力與虐待事件的社會因素包括那些？①工作壓力 ②家庭管教方式 ③媒體學習 ④醫療制度",106,"2026-09-04",1788510740013]