[{"data":1,"prerenderedAt":67},["ShallowReactive",2],{"q-nurse-113-1-fundamental-nursing-035":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-113-1-基本護理學與護理行政-035","nurse-113-1-fundamental-nursing-035",113,1,35,"下列何者為臨終病人的瀕死症狀？①脈搏出現奇異脈（paradoxical pulse） ②張口呼吸 ③肛門括約肌收縮 ④吞嚥困難",{"A":15,"B":16,"C":17,"D":18},"①②","①④","②③","②④","D",null,[],"本題考點在於辨識臨終病人的瀕死症狀。臨終瀕死期因循環衰竭、肌張力喪失與神經反射退化,依生理表現可判斷：②張口呼吸(下顎垂落、呼吸費力)與④吞嚥困難(吞嚥反射消失、分泌物積聚)為典型瀕死徵象,故選 D。①奇異脈(paradoxical pulse)是吸氣時收縮壓下降超過 10 mmHg,見於心包填塞、氣喘等,並非瀕死特徵。③肛門括約肌是「鬆弛」而非「收縮」,故臨終常見大小便失禁,敘述方向相反。因此正確組合為②④。","瀕死期(active dying)常見表現可歸納為循環、呼吸、神經三系統崩解：循環面出現末梢發紺、脈搏細弱、血壓下降;呼吸面出現張口呼吸、陳施氏呼吸(Cheyne-Stokes)與臨終喉鳴(death rattle);神經肌肉面則是肌張力喪失、反射消失,導致吞嚥困難、括約肌鬆弛而失禁。記憶重點：瀕死是「鬆」不是「緊」,任何提到括約肌收縮的選項都可先排除。奇異脈屬心血管特殊評估,和瀕死無關,常拿來當混淆選項。",[25,28,30,32,34],{"term":26,"count":27},"奇異脈",2,{"term":29,"count":11},"瀕死症狀",{"term":31,"count":11},"張口呼吸",{"term":33,"count":11},"吞嚥反射消失",{"term":35,"count":11},"括約肌鬆弛失禁",[37,41,46,51,56,61],{"webId":38,"stem":39,"number":40,"year":10,"session":11},"nurse-113-1-fundamental-nursing-036","有關目標管理，下列敘述何者正確？",36,{"webId":42,"stem":43,"number":44,"year":10,"session":45},"nurse-113-3-fundamental-nursing-032","針對傳染病病房於病人出院後的處理方式，下列敘述何者正確？",32,3,{"webId":47,"stem":48,"number":49,"year":50,"session":27},"nurse-114-2-fundamental-nursing-026","下列何者不是易發生高壓脈（pulse of high tension）的族群？",26,114,{"webId":52,"stem":53,"number":54,"year":55,"session":11},"nurse-106-1-fundamental-nursing-024","下列溶液何者可於輸血前後使用於同一條輸液管路？",24,106,{"webId":57,"stem":58,"number":59,"year":60,"session":11},"nurse-107-1-fundamental-nursing-068","對於組織控制幅度（span of control）的敘述，下列何者正確？",68,107,{"webId":62,"stem":63,"number":64,"year":65,"session":27},"nurse-108-2-fundamental-nursing-022","護理師處理醫囑 zolpidem（stilnox）1 # P.O. bid，當其對此醫囑有疑問時，下列何者為最適當的處理？",22,108,"2026-09-04",1788510750103]