[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-113-1-medical-surgical-047":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":32,"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":10},"nurse-113-1-內外科護理學-047","nurse-113-1-medical-surgical-047",113,1,47,"有關休克病人體溫下降之護理措施，下列何者正確？",{"A":14,"B":15,"C":16,"D":17},"當身體顫抖產熱及代謝增加，應調低室溫以減少發燒程度","靜脈注射的液體或血液，應加溫至接近正常體溫","使用熱水袋或電毯包裹四肢","給予熱水浴，以增加病人舒適感","B",null,[],"本題考點在於休克病人低體溫的正確保暖原則。休克時周邊血管收縮、組織灌流不足，體溫下降，處置目標是溫和回溫並避免加重代謝耗氧。依此原則，B「靜脈輸注的液體或血液應加溫至接近正常體溫」正確，可避免大量冰冷輸液造成核心體溫進一步下降與心律不整。A「調低室溫以減少發燒」錯誤，休克顫抖是產熱代償，降室溫反使體溫更低、耗氧更多。C「用熱水袋或電毯包裹四肢」錯誤，直接局部加熱會使周邊血管擴張、血液流向四肢，減少重要器官灌流並有燙傷風險。D「給予熱水浴」同理會造成周邊血管擴張、血壓下降，且不適用於循環不穩病人。故正解為 B。","病生理重點：休克保暖強調『核心優先、被動回溫、避免周邊快速血管擴張』。周邊突然擴張會造成回心血量與血壓驟降（rewarming shock\u002Fafterdrop），故不用熱水袋、電毯直接烤四肢。正確做法為調高室溫、蓋乾暖毛毯、輸注加溫過的液體或血品。低溫還會抑制凝血酶功能形成『致命三角』（低體溫、酸中毒、凝血病變），大量輸血時尤須加溫。可連結創傷急救的損害控制復甦概念。",[24,26,28,30],{"term":25,"count":10},"休克",{"term":27,"count":10},"低體溫保暖原則",{"term":29,"count":10},"加溫輸液",{"term":31,"count":10},"周邊血管擴張",[33,37,42,48,53,58],{"webId":34,"stem":35,"number":36,"year":9,"session":10},"nurse-113-1-medical-surgical-048","有關食物中毒之敘述，下列何者正確？",48,{"webId":38,"stem":39,"number":40,"year":9,"session":41},"nurse-113-3-medical-surgical-044","有關糖尿病病人足部護理的指導，下列何者正確？①每日以溫水清洗足部前須以手背測試水溫，以防燙傷 ②修剪趾甲應剪短於足趾末端，以防甲溝炎 ③平日於足部與足趾間及腳跟龜裂處，塗抹保養乳液，以免皮膚過於乾燥 ④不可擅自用手或剪刀，將足部硬繭或雞眼剝除",44,3,{"webId":43,"stem":44,"number":45,"year":46,"session":47},"nurse-114-2-medical-surgical-038","有關血液透析病人動靜脈瘻管（A-V fistula）之護理措施，下列何者正確？",38,114,2,{"webId":49,"stem":50,"number":51,"year":52,"session":10},"nurse-106-1-medical-surgical-036","有關惡性腫瘤特性之敘述，下列何者錯誤？",36,106,{"webId":54,"stem":55,"number":56,"year":57,"session":10},"nurse-107-1-medical-surgical-080","有關登革熱之處置，下列何者錯誤？",80,107,{"webId":59,"stem":60,"number":61,"year":62,"session":47},"nurse-108-2-medical-surgical-034","有關多發性骨髓瘤的臨床症狀，下列何者錯誤？",34,108,"2026-09-04",1788510750613]