[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-113-1-psychiatric-community-011":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":34,"lastmod":62},"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-113-1-精神科與社區衛生護理學-011","nurse-113-1-psychiatric-community-011",113,1,11,"王小姐有被害妄想，一直擔心家人在食物中下毒，入院後仍不肯進食。下列何者是最優先的護理措施？",{"A":14,"B":15,"C":16,"D":17},"請醫師立即插鼻胃管給予灌食","告知病人再不進食，要進保護室","請病人家屬準備伙食","協助病人自行採購包裝完整的食物","D",null,[],"本題考點在於被害妄想(下毒妄想)病人拒食的優先護理措施。依妄想症狀護理原則,不與妄想爭辯、也不強化妄想,而是在尊重病人現實感受下確保生理需求;提供密封、包裝完整的食物並讓病人自行挑選,可繞過「食物被下毒」的疑慮,兼顧自主權與營養攝取,故選 D。A 立即插鼻胃管灌食屬侵入性強制措施,僅在生命徵象受威脅、其他方法皆無效時才考慮,非最優先;B 以進保護室威脅病人是懲罰性語言,破壞信任且違反治療性關係;C 請家屬準備伙食行不通,因病人的妄想內容正是「家人在食物中下毒」,反而加深恐懼。","妄想護理三原則:不爭辯(爭辯會強化防衛)、不附和(附和會強化妄想)、聚焦感受與現實需求。拒食處理階梯:先提供病人可信任的食物來源(密封包裝、罐頭、自行選購、當面拆封)→ 陪伴進食、觀察攝入量與體重 → 均無效且出現脫水\u002F營養不良徵象時,才依醫囑考慮靜脈注射或鼻胃管。本題陷阱在 C:一般拒食情境「家屬送飯」常是可行選項,但此病人妄想對象正是家人,凸顯「護理措施須貼合妄想內容個別化」的考點。延伸:被害妄想常見於思覺失調症妄想型,藥物以抗精神病藥為主。",[24,27,30,32],{"term":25,"count":26},"治療性人際關係",12,{"term":28,"count":29},"病人自主權",2,{"term":31,"count":10},"被害妄想護理原則",{"term":33,"count":10},"拒食病人處理階梯",[35,38,43,47,52,57],{"webId":36,"stem":37,"number":26,"year":9,"session":10},"nurse-113-1-psychiatric-community-012","有關思覺失調症病人常不規則服藥，下列何項出院藥物護理最不適切？",{"webId":39,"stem":40,"number":41,"year":9,"session":42},"nurse-113-3-psychiatric-community-008","高小姐罹患「雙相情緒障礙症」，因情緒高昂，整天在家裡不停翻箱倒櫃忙進忙出，表示自己是神力女超人，不需進食，晚上不睡覺一直打電話給警局要一起去拯救世界，故家人帶她入院治療，下列高小姐護理問題何者適切？①營養攝取不足 ②現存性自我傷害 ③睡眠型態紊亂 ④恐懼",8,3,{"webId":44,"stem":45,"number":29,"year":46,"session":29},"nurse-114-2-psychiatric-community-002","有關治療性人際關係的敘述，下列何者錯誤？",114,{"webId":48,"stem":49,"number":50,"year":51,"session":29},"nurse-115-2-psychiatric-community-050","有關慢性腎臟病飲食衛教指導，下列何者最不適當？",50,115,{"webId":53,"stem":54,"number":55,"year":56,"session":10},"nurse-107-1-psychiatric-community-044","食用未煮熟雞蛋而導致腸道疾病，最常見之細菌為何？",44,107,{"webId":58,"stem":59,"number":60,"year":61,"session":29},"nurse-108-2-psychiatric-community-078","承上題，為讓李太太有機會了解類似狀況家庭照顧者的經驗，以增加其心理適應，社區衛生護理師可轉介她使用下列那一項服務？",78,108,"2026-09-04",1788510751145]