[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-112-1-fundamental-nursing-054":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":34,"lastmod":63},"基本護理學與護理行政","fundamental-nursing","基本護理學(包括護理原理、護理技術)與護理行政",{"id":8,"webId":9,"year":10,"session":11,"subject":4,"number":12,"stem":13,"options":14,"answer":19,"answerNote":20,"images":21,"explanation":22,"explanationDeep":23,"topics":24,"freq":27},"nurse-112-1-基本護理學與護理行政-054","nurse-112-1-fundamental-nursing-054",112,1,54,"王先生因肺癌末期，依其各系統生理上出現的變化判定即將臨終，下列敘述何者錯誤？",{"A":15,"B":16,"C":17,"D":18},"感覺功能消失","吸氣時胸壁內陷，呼氣時外突","四肢出現發紺現象","視力改變","B",null,[],"本題考點在於臨終病人各系統的生理變化，須找出錯誤敘述。臨終時感覺與知覺功能逐漸消退（A，聽覺通常最後消失）、周邊循環變差使四肢發紺（C）、視力模糊改變（D），這些皆為正確的臨終表現。考點在於 B「吸氣時胸壁內陷、呼氣時外突」——這是反常呼吸型態的描述，正常吸氣應是胸廓「擴張外突」、呼氣時回縮，B 將方向敘述顛倒，不符臨終呼吸生理，故為錯誤敘述，正解 B。臨終呼吸多見潮式（Cheyne-Stokes）或臨終喉鳴，而非題中所述的胸壁內外運動反向。","臨終常見變化：知覺退化（聽覺最後失去，故仍應輕聲陪伴）、循環衰竭致肢端發紺冰冷、Cheyne-Stokes 潮式呼吸與臨終喉鳴、括約肌鬆弛失禁。正常呼吸吸氣胸廓外擴，題目 B 把吸呼運動方向寫反即為破綻。記法「臨終聽覺最晚走、末梢先發紫」。",[25,28,30,32],{"term":26,"count":27},"臨終生理變化",5,{"term":29,"count":11},"感覺功能消退",{"term":31,"count":11},"末梢發紺",{"term":33,"count":11},"呼吸型態",[35,39,44,49,54,59],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-112-1-fundamental-nursing-055","吳爺爺，肺癌合併腦、骨頭多處轉移，骨轉移疼痛目前有 Morphine 10 mg S.C. q4h+p.r.n.使用，臨終階段出現譫妄、躁動不安之情形，案妻詢問醫療人員：「看他這樣很捨不得，可以用點藥讓他休息一下嗎？」醫療人員如何回應較為適宜？",55,{"webId":40,"stem":41,"number":42,"year":10,"session":43},"nurse-112-2-fundamental-nursing-071","有關全責護理模式（primary nursing care model）之敘述，下列何者正確？",71,2,{"webId":45,"stem":46,"number":47,"year":48,"session":11},"nurse-113-1-fundamental-nursing-035","下列何者為臨終病人的瀕死症狀？①脈搏出現奇異脈（paradoxical pulse） ②張口呼吸 ③肛門括約肌收縮 ④吞嚥困難",35,113,{"webId":50,"stem":51,"number":52,"year":53,"session":43},"nurse-114-2-fundamental-nursing-033","傳染性病人出院後，病人單位的終期消毒（terminal disinfection）方式，下列何者正確？",33,114,{"webId":55,"stem":56,"number":57,"year":58,"session":11},"nurse-106-1-fundamental-nursing-037","陳先生剛從大陸返台，持續兩天高燒不退，至門診就醫治療，主訴：這兩天身體一直燙燙的，耳溫都約維持 38.5～39.5℃。下列何者是陳先生可能的發燒型態？",37,106,{"webId":60,"stem":61,"number":42,"year":62,"session":11},"nurse-107-1-fundamental-nursing-071","效率標準和效能標準評值之比較敘述，以下何者錯誤？",107,"2026-09-04",1788510741423]