[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-113-1-medical-surgical-003":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":34,"lastmod":63},"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-113-1-內外科護理學-003","nurse-113-1-medical-surgical-003",113,1,3,"有關頭部外傷病人顱內壓升高的處置，下列何者錯誤？",{"A":14,"B":15,"C":16,"D":17},"急性期可裝置顱內壓監測器，依醫囑引流腦脊髓液降低顱內壓","病人的格拉斯哥昏迷量表（GCS）總分為5分，表示病人處於昏迷狀態","使用Mannitol 降腦壓時，使用前後要注意血糖的變化","若病人的瞳孔突然放大、對光沒有反應或是固定、肌力及意識下降，有可能是顱內壓升高","C",null,[],"本題考點在於頭部外傷顱內壓升高(IICP)的處置,為反向題(問何者「錯誤」)。錯誤敘述為 C——Mannitol 為滲透性利尿劑,使用前後應監測的是「電解質、腎功能、尿量與血漿滲透壓」,而非血糖,故 C 錯誤而為答案。A 急性期放置顱內壓監測器並依醫囑引流腦脊髓液以降腦壓,正確;B GCS 總分 5 分(3–8 分)確實代表昏迷狀態,正確;D 瞳孔突然放大、對光反應消失或固定、肌力與意識下降,是顱內壓升高、腦幹受壓(腦疝)的危險徵象,正確。因此選 C。","IICP 處置目標在降低腦容積:抬高床頭 30 度、維持頭頸中線、避免屏氣與腹壓上升、控制體溫與二氧化碳。Mannitol 藉滲透壓將組織水分拉回血管再由腎排出,護理重點為監測尿量、血清電解質(尤其鈉)、腎功能與血漿滲透壓,並注意脫水與電解質不平衡;它與血糖監測無直接關聯(需監測血糖的是類固醇或胰島素治療)。GCS 分級:13–15 輕度、9–12 中度、3–8 重度(昏迷)。庫欣氏三聯徵(血壓升高併脈壓增大、心搏過緩、呼吸型態改變)是 IICP 惡化的警訊。",[24,27,30,32],{"term":25,"count":26},"顱內壓升高",11,{"term":28,"count":29},"Mannitol滲透性利尿劑",2,{"term":31,"count":10},"GCS昏迷分級",{"term":33,"count":10},"電解質與腎功能監測",[35,39,43,48,53,58],{"webId":36,"stem":37,"number":38,"year":9,"session":10},"nurse-113-1-medical-surgical-004","有關阿茲海默氏症之敘述，下列何者錯誤？",4,{"webId":40,"stem":41,"number":42,"year":9,"session":29},"nurse-113-2-medical-surgical-050","有關臘腸桿菌（Clostridium botulinum）中毒的預防、症狀與治療之敘述，下列何者正確？",50,{"webId":44,"stem":45,"number":46,"year":47,"session":10},"nurse-114-1-medical-surgical-044","有關肢端肥大症之症狀，下列何者錯誤？",44,114,{"webId":49,"stem":50,"number":51,"year":52,"session":29},"nurse-115-2-medical-surgical-042","有關急性腎盂腎炎病人的敘述，下列何者錯誤？",42,115,{"webId":54,"stem":55,"number":56,"year":57,"session":10},"nurse-107-1-medical-surgical-036","有關癌症疼痛治療三階段給藥之敘述，下列何者正確？①定時給藥 ②需要時給藥 ③口服優先 ④先考慮靜脈注射給藥 ⑤優先考慮低效性麻醉劑 ⑥先從非麻醉性製劑開始",36,107,{"webId":59,"stem":60,"number":61,"year":62,"session":10},"nurse-108-1-medical-surgical-070","下列何者最可能造成病人出現昏迷、呼吸快而深、血清有效滲透壓 300 mOsm\u002Fkg、血糖值 400 mg\u002FdL 的臨床表徵？",70,108,"2026-09-04",1788510750250]