[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-112-2-medical-surgical-078":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":35,"lastmod":64},"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-078","nurse-112-2-medical-surgical-078",112,2,78,"當車禍造成嚴重創傷的病人送到急診出現：脈搏 124 次／分、呼吸 32 次／分胸部起伏明顯，血壓 130\u002F100 mmHg、皮膚溼且冰冷、尿量減少、呈現呼吸性鹼中毒情形，下列休克階段的分期，何者正確？",{"A":14,"B":15,"C":16,"D":17},"早期","代償期","進行期","不可逆期","B",null,[],"本題考點在依臨床表現判斷休克的分期。考點在於辨識代償期的特徵:血管收縮使舒張壓升高、脈壓變窄(130\u002F100),心跳與呼吸代償性加快、皮膚因周邊血管收縮而溼冷、尿量減少反映腎灌流下降，且過度換氣造成呼吸性鹼中毒，這些都顯示身體正啟動代償機轉維持重要器官灌流,故選 B 代償期。A 早期未列於標準四分期用語。C 進行期時代償失效、血壓明顯下降、酸中毒出現，與本題血壓仍能維持不符。D 不可逆期則多重器官衰竭、對治療無反應。故最符合代償期。","休克分期(代償→進行→不可逆)看代償機轉是否還撐得住。代償期靠交感神經興奮:心跳快、周邊血管收縮(舒張壓升、脈壓窄、皮膚溼冷)、腎素-血管收縮素保鈉保水(尿量減少)、過度換氣先造成呼吸性鹼中毒。進行期代償失效:低血壓、代謝性酸中毒(乳酸堆積)、意識改變。不可逆期:細胞壞死、DIC、多重器官衰竭。判讀關鍵「血壓還撐住+脈壓窄+溼冷=代償期」;一旦血壓崩、酸中毒=進行期。可連結各類休克(低血容、心因、分佈性)血流動力學對比複習。",[24,27,29,32,33],{"term":25,"count":26},"呼吸性鹼中毒",3,{"term":28,"count":10},"脈壓變窄",{"term":30,"count":31},"休克分期",1,{"term":15,"count":31},{"term":34,"count":31},"交感代償周邊血管收縮",[36,40,45,49,54,59],{"webId":37,"stem":38,"number":39,"year":9,"session":10},"nurse-112-2-medical-surgical-079","有關嚴重特殊傳染性肺炎 COVID-19 之護理措施，下列何者正確？",79,{"webId":41,"stem":42,"number":43,"year":44,"session":31},"nurse-113-1-medical-surgical-045","張太太，罹患糖尿病2年，平日使用口服抗血糖藥物控制血糖，今日在家昏倒被送至急診，醫師初步診斷為高滲透壓高血糖狀態（HHS），病人會呈現的徵象，下列何者正確？①呼吸速率26次／分 ②血壓166\u002F84 mmHg ③尿酮呈陽性反應，明顯升高 ④血糖為750 mg\u002FdL。",45,113,{"webId":46,"stem":47,"number":48,"year":44,"session":26},"nurse-113-3-medical-surgical-039","有關體外震波碎石術之敘述，下列何者錯誤？",39,{"webId":50,"stem":51,"number":52,"year":53,"session":31},"nurse-115-1-medical-surgical-037","提供腎絲球過濾率為17 mL\u002Fmin\u002F1.73 m 2的病人之護理指導，下列何者正確？",37,115,{"webId":55,"stem":56,"number":57,"year":58,"session":10},"nurse-106-2-medical-surgical-061","有關睪丸癌最主要的危險因子，下列何者正確？",61,106,{"webId":60,"stem":61,"number":62,"year":63,"session":31},"nurse-108-1-medical-surgical-015","有關迴腸造口手術後造瘻口的正常顏色，下列何者正確？",15,108,"2026-09-04",1788510747963]