[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-112-2-fundamental-nursing-040":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":11},"nurse-112-2-基本護理學與護理行政-040","nurse-112-2-fundamental-nursing-040",112,2,40,"急診室接到重大車禍傷患，到院時意識不清，血壓只有 70\u002F35 mmHg，懷疑內出血，下列敘述何者正確？",{"A":15,"B":16,"C":17,"D":18},"需雙手同時按壓頸動脈測量脈動","因脈動過速而出現高壓脈的狀況","脈波微弱做觸診會有摸不到情況","脈搏震幅交替產生強弱不穩狀態","C",null,[],"本題考點是低血容性休克時脈搏的觸診特徵。血壓 70\u002F35 mmHg、疑內出血屬低血容性休克,依血流動力學,心輸出量與周邊灌流下降使脈波振幅微弱,觸診時脈搏細弱難尋、甚至摸不到(絲脈,thready pulse),故 C 正確。A 錯,絕不可雙手同時按壓兩側頸動脈,會阻斷腦部血流並可能引發迷走反射導致心律變化,極度危險。B 錯,休克時血壓下降,不會出現「高壓脈(洪脈)」;洪脈見於發燒、甲亢等高輸出狀態。D 錯,脈搏強弱交替(交替脈,pulsus alternans)是左心衰竭的表現,與低血容休克的絲脈機轉不同。","低血容性休克時,身體經交感神經代償使心跳加速(脈快)、周邊血管收縮以維持核心灌流,故脈搏呈「快而弱」的絲脈,血壓下降、脈壓變窄。特殊脈搏須鑑別:洪脈(bounding)見於高心輸出如發燒、貧血、甲亢;交替脈(規律但強弱交替)提示左心衰竭;奇脈(pulsus paradoxus,吸氣時收縮壓下降>10 mmHg)見於心包填塞、氣喘。臨床測頸動脈脈搏一次只能單側輕觸,雙側同壓為絕對禁忌。掌握「休克=快而弱的絲脈」即可鎖定答案並排除心衰型脈象。",[25,27,30,32],{"term":26,"count":11},"低血容性休克",{"term":28,"count":29},"絲脈(thready pulse)",1,{"term":31,"count":29},"頸動脈觸診禁忌",{"term":33,"count":29},"交替脈與左心衰竭",[35,39,44,48,53,58],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-112-2-fundamental-nursing-041","有關脈搏測量部位的敘述，下列何者正確？",41,{"webId":40,"stem":41,"number":42,"year":43,"session":29},"nurse-113-1-fundamental-nursing-007","手術後第2天，病人於8：30 AM下床活動後主訴傷口痛且臉色蒼白、盜冷汗，醫師評估後於9 AM給予止痛藥。下列何者為最適當的評值？",7,113,{"webId":45,"stem":46,"number":29,"year":43,"session":47},"nurse-113-3-fundamental-nursing-001","競賽前，短跑選手感覺自己的心跳快速、肌肉收縮、口乾、並且全身冒汗，此時該選手正經歷全身適應症候群（general adaptation syndrome）的那個階段？",3,{"webId":49,"stem":50,"number":51,"year":52,"session":47},"nurse-114-3-fundamental-nursing-049","護理部編列年度預算，下列何者屬於直接成本？",49,114,{"webId":54,"stem":55,"number":56,"year":57,"session":11},"nurse-106-2-fundamental-nursing-023","小美沿著靜脈注射處有發紅現象，輸液注入速度變慢，此時下列護理處置何者正確？",23,106,{"webId":59,"stem":60,"number":61,"year":62,"session":11},"nurse-107-2-fundamental-nursing-057","某護理機構承製某項產品之固定成本為 50,000 元，每服務件數之變動成本（variable cost）為 150 元，銷售價為 250 元。該產品損益平衡點（break-even point）之服務件數為多少？",57,107,"2026-09-04",1788510746917]