[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-112-2-medical-surgical-018":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":34,"lastmod":62},"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-112-2-內外科護理學-018","nurse-112-2-medical-surgical-018",112,2,18,"右小腿上石膏病人，出現下列何項臨床表徵，需要立即給予處理？",{"A":14,"B":15,"C":16,"D":17},"右腳大拇趾甲床微血管充填時間 2 秒","右腳小腿末端出現感覺異常","右小腿石膏內皮膚發癢","右側足背動脈脈搏強度 2+","B",null,[],"本題考點是石膏固定後的神經血管評估（5P 原則）與筋膜室症候群的早期警訊，需立即處理的是 B。依肢體循環與神經評估，感覺異常（paresthesia，麻木刺痛）是石膏過緊或筋膜室症候群壓迫神經的早期危險徵象，若不及時處理恐致不可逆的神經肌肉缺血損傷，故 B 需立即處置。A 甲床微血管充填時間 2 秒屬正常（正常＜3 秒），非異常；C 石膏內皮膚發癢是常見不適，衛教勿將物品塞入石膏內搔抓即可，非緊急；D 足背動脈脈搏 2+ 代表脈搏正常可觸及、循環良好，非異常，故選 B。","肢體固定後的循環神經評估以「5P（或 6P）」為框架：Pain（疼痛，尤其被動牽張時劇痛）、Pallor（蒼白）、Paresthesia（感覺異常）、Pulselessness（脈搏消失）、Paralysis（麻痺），有時加 Poikilothermia（患肢變冷）。其中感覺異常與被動牽張劇痛出現最早，是筋膜室症候群的關鍵警訊；脈搏消失與麻痺屬晚期、代表已嚴重缺血。筋膜室症候群是石膏或腫脹使密閉筋膜室壓力升高、阻斷微循環的急症，處置爭取時間以避免六小時內的不可逆壞死，通常需鬆開或剖開石膏、必要時筋膜切開術。本題與下一題（019）連貫，正是此臨床情境的處置延伸。",[24,27,29,31],{"term":25,"count":26},"石膏護理",4,{"term":28,"count":10},"感覺異常",{"term":30,"count":10},"筋膜室症候群",{"term":32,"count":33},"5P神經血管評估",1,[35,39,44,49,54,58],{"webId":36,"stem":37,"number":38,"year":9,"session":10},"nurse-112-2-medical-surgical-019","承上題，下列何者為病人最適當的處置？",19,{"webId":40,"stem":41,"number":42,"year":9,"session":43},"nurse-112-3-medical-surgical-035","病人的動脈血液氣體分析報告為 pH 7.36，PaO 2 88 mmHg，PaCO 2 50 mmHg，HCO 3- 25 mEq\u002FL，下列措施何者應為最優先？",35,3,{"webId":45,"stem":46,"number":47,"year":48,"session":10},"nurse-113-2-medical-surgical-029","有關全身性紅斑性狼瘡之醫療處置之敘述，下列何者錯誤？",29,113,{"webId":50,"stem":51,"number":52,"year":53,"session":43},"nurse-114-3-medical-surgical-027","成人燒傷部位與範圍包括左上肢全部、左下肢正面及軀幹正面，依據九法則評估其燒傷面積為何？",27,114,{"webId":55,"stem":56,"number":33,"year":57,"session":10},"nurse-106-2-medical-surgical-001","林先生因頭部外傷需要裝置顱內壓監測系統的敘述，下列何者錯誤？",106,{"webId":59,"stem":60,"number":42,"year":61,"session":10},"nurse-107-2-medical-surgical-035","有關深部血栓靜脈炎病人之護理措施，下列何者不適當？",107,"2026-09-04",1788510747412]