[{"data":1,"prerenderedAt":68},["ShallowReactive",2],{"q-nurse-112-3-psychiatric-community-021":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":37,"lastmod":67},"精神科與社區衛生護理學","psychiatric-community",{"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-112-3-精神科與社區衛生護理學-021","nurse-112-3-psychiatric-community-021",112,3,21,"邵女士，67 歲，因車禍接受手術，在加護病房第二天出現混亂、慌張、不安、定向障礙之症狀，小夜班時不斷拉鈴要求出去，大夜班時跟護理師反映牆壁上有許多蟑螂。針對此譫妄（delirium）狀態，下列何項護理措施最適宜？",{"A":14,"B":15,"C":16,"D":17},"儘可能採約束隔離措施，以免病人出現更混亂的行為","病人能參與定向感訓練，增進認知功能","增加感官刺激活動，以緩和病人緊張情緒","提供病人安全、安靜舒適的環境","D",null,[],"本題考點在於譫妄(delirium)的環境性護理措施。依譫妄照護原則,病人處於急性意識混亂、定向障礙合併幻覺(牆上有蟑螂為視幻覺),護理重點是提供安全、安靜、舒適且刺激適度的環境以減少混亂,故選 D。A「儘可能約束隔離」錯誤,過度約束反而增加躁動與傷害,約束應為最後手段。B「病人能參與定向感訓練」不當,急性混亂期病人認知功能受損,無法有效參與結構化訓練,且此為期望目標非當下措施。C「增加感官刺激活動」錯誤,譫妄應減少而非增加過度刺激,以免加重混亂。考點在於辨識譫妄須降低刺激並維護安全環境。","譫妄特徵為急性發作、病程起伏(日輕夜重,sundowning)、注意力與意識波動,常見於術後、加護病房、感染或電解質失衡。照護原則:找出並處理誘因(疼痛、缺氧、感染、藥物)、提供適當光線與熟悉物品協助定向、白天增加活動、夜間減少干擾以維持日夜節律。對比:譫妄可逆且急性,失智為慢性漸進,是常考鑑別。",[24,27,29,32,35],{"term":25,"count":26},"譫妄",6,{"term":28,"count":10},"約束為最後手段",{"term":30,"count":31},"定向感維護",2,{"term":33,"count":34},"安全安靜環境",1,{"term":36,"count":34},"降低過度刺激",[38,42,47,52,57,62],{"webId":39,"stem":40,"number":41,"year":9,"session":10},"nurse-112-3-psychiatric-community-022","有關心理防衛機轉的敘述，下列何者正確？",22,{"webId":43,"stem":44,"number":45,"year":46,"session":31},"nurse-113-2-psychiatric-community-018","有關物質使用障礙症病人的護理措施，下列敘述何者不適切？",18,113,{"webId":48,"stem":49,"number":50,"year":51,"session":34},"nurse-114-1-psychiatric-community-012","陳同學19歲，出現怪異行為，診斷為思覺失調症。因為干擾鄰居被送至精神科急性病房住院。入院時，說自己沒有生病，吵著要出院回家。以下何項護理措施最適切？",12,114,{"webId":53,"stem":54,"number":55,"year":56,"session":31},"nurse-115-2-psychiatric-community-010","下列有關憂鬱症病因之敘述何者正確？①病人最常使用的防禦機轉為內射 ②病人的本我弱，超我強 ③病人對自我有負向看法，這是屬於認知理論 ④當憂鬱情緒好轉時，自殺的意念就會消失",10,115,{"webId":58,"stem":59,"number":60,"year":61,"session":34},"nurse-107-1-psychiatric-community-004","下列何者屬於精神衛生法所保障的精神病人權益？",4,107,{"webId":63,"stem":64,"number":65,"year":66,"session":31},"nurse-108-2-psychiatric-community-038","有關自殺危險因子之說明，下列敘述何者正確？①自殺危險因子廣布於生物、心理、社會、經濟、文化層面，絕非單一因素 ②自殺危險因子具有快速變動與不易測度的特質，故此自殺防範應單一統由專責人員負責 ③自殺的危險遠端因子中包括精神科疾病、致命工具的可近性 ④社會心理因素會與自殺相關，如重大失落事件",38,108,"2026-09-04",1788510745889]