[{"data":1,"prerenderedAt":67},["ShallowReactive",2],{"q-nurse-112-3-fundamental-nursing-034":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":36,"lastmod":66},"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-112-3-基本護理學與護理行政-034","nurse-112-3-fundamental-nursing-034",112,3,34,"大腸直腸癌末期合併多處轉移病人，呈現意識時而嗜睡，時而清醒，臨床評估下列那些是瀕死症狀？ ①訴說看到過世的親友 ②譫妄躁動 ③出現深且快的呼吸型態 ④畢歐氏呼吸（Biot’s respiration） ⑤全身皮膚乾燥",{"A":15,"B":16,"C":17,"D":18},"①②","②③","③④","④⑤","A",null,[],"本題考點在於瀕死（臨終）症狀的辨識。依臨終生理變化，此意識時清時睡的末期病人出現①訴說看到已過世親友（臨終覺知、意識改變）與②譫妄躁動（末期躁動）皆屬典型瀕死症狀，故選 A（①②）。③「深且快的呼吸型態」較符合代謝性酸中毒的庫斯莫氏呼吸，非臨終特有；④畢歐氏呼吸（Biot's respiration）雖見於腦部病變，但臨終最典型的是漸強漸弱交替的陳施氏呼吸（Cheyne-Stokes），畢歐氏並非題示情境首選；⑤瀕死末梢循環變差常見皮膚濕冷、發紺而非全身乾燥。故含③④⑤者皆不符。","臨終常見徵象：意識改變（嗜睡、譫妄躁動、臨終覺知\u002F看見亡故親友）、呼吸型態改變以陳施氏呼吸與瀕死喉鳴（death rattle）為主、末梢循環衰竭致四肢濕冷發紺、脈弱血壓降、尿量減少。畢歐氏與庫斯莫氏呼吸各有特定病因（腦幹病變、酸中毒），屬鑑別陷阱，勿與臨終的陳施氏呼吸混淆。",[25,28,31,34],{"term":26,"count":27},"陳施氏呼吸",4,{"term":29,"count":30},"末梢循環衰竭",2,{"term":32,"count":33},"臨終瀕死症狀",1,{"term":35,"count":33},"臨終覺知與末期躁動",[37,41,46,51,56,61],{"webId":38,"stem":39,"number":40,"year":10,"session":11},"nurse-112-3-fundamental-nursing-035","罹患大腸直腸癌末期病人，生命存活期有限，因早年喪偶，一手拉拔兒女長大成人，與兒孫關係緊密，有關引導病人進行生命回顧的敘述，下列何者最適當？",35,{"webId":42,"stem":43,"number":44,"year":45,"session":30},"nurse-113-2-fundamental-nursing-031","適當的飲食原則為均衡地攝取六大類食物，下列敘述何者錯誤？",31,113,{"webId":47,"stem":48,"number":49,"year":50,"session":33},"nurse-114-1-fundamental-nursing-025","關於影響呼吸頻率的因素，下列敘述何者錯誤？",25,114,{"webId":52,"stem":53,"number":54,"year":55,"session":30},"nurse-115-2-fundamental-nursing-023","護理師協助意識昏迷且已臥床三個月的 80 歲病人測量體溫時，下列關於體溫測量技術與結果判讀，何者正確？",23,115,{"webId":57,"stem":58,"number":59,"year":60,"session":33},"nurse-107-1-fundamental-nursing-017","李先生手術後回到病房，手臂上留有靜脈滴注之管路，主訴疼痛程度為 8 分（用 0～10 分之疼痛評估量表），護理師查看醫囑單，醫囑為：「Demerol 40 mg q.4h. p.r.n. for pain」，依據病人目前情況及醫囑，護理師最適當的行動為何？",17,107,{"webId":62,"stem":63,"number":64,"year":65,"session":33},"nurse-108-1-fundamental-nursing-051","有關安寧療護的敘述，下列何者正確？",51,108,"2026-09-04",1788510744615]