[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-113-2-medical-surgical-002":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":33,"lastmod":62},"內外科護理學","medical-surgical",{"id":7,"webId":8,"year":9,"session":10,"subject":4,"number":10,"stem":11,"options":12,"answer":17,"answerNote":18,"images":19,"explanation":20,"explanationDeep":21,"topics":22,"freq":25},"nurse-113-2-內外科護理學-002","nurse-113-2-medical-surgical-002",113,2,"有關顱底骨骨折病人有耳漏、鼻漏的評估與及處置，下列敘述何者錯誤？",{"A":13,"B":14,"C":15,"D":16},"用面紙吸取滴下的耳漏、鼻漏液體會有光暈徵象","教導不可用力咳嗽及打噴嚏","指導臥床休息以利腦膜貼附癒合","以無菌原則抽吸病人鼻孔內液體","D",null,[],"本題考點在於顱底骨折併發腦脊髓液(CSF)耳漏、鼻漏的評估與照護,本題為找出錯誤敘述的反向題。以無菌方式抽吸病人鼻孔內液體是錯誤作法,因抽吸會增加逆行性感染與腦膜炎風險,也可能加重 CSF 漏,故 D 為錯誤敘述,即本題答案。A 正確:CSF 混血滴於紗布或面紙會呈中央血跡、外圍清亮的光暈徵象(halo\u002Fring sign),可協助辨識 CSF 漏;B 正確:應教導避免用力咳嗽、擤鼻、打噴嚏,以免升高顱內壓、加重漏液;C 正確:臥床休息並適度抬高床頭,有助腦膜自行貼附癒合。故選 D。","CSF 漏辨識與照護:光暈徵象與葡萄糖試紙陽性(CSF 含糖,鼻黏液不含)可輔助判斷。照護重點為「不阻塞、不逆行、不升壓」——鼻漏不塞棉條、不抽吸、不置鼻胃管,避免擤鼻與用力動作,床頭適度抬高促進癒合。抽吸鼻腔會把外界細菌帶入顱內,是本題最典型的錯誤陷阱。",[23,26,28,31],{"term":24,"count":25},"顱底骨折",4,{"term":27,"count":25},"腦脊髓液漏",{"term":29,"count":30},"光暈徵象",1,{"term":32,"count":30},"顱內感染預防",[34,38,42,47,52,57],{"webId":35,"stem":36,"number":37,"year":9,"session":10},"nurse-113-2-medical-surgical-003","有關癲癇重積狀態（status epilepticus）的敘述，下列何者錯誤？",3,{"webId":39,"stem":40,"number":41,"year":9,"session":37},"nurse-113-3-medical-surgical-049","下列何者不是骨折病人應該要密切觀察 6P 的徵象或症狀？",49,{"webId":43,"stem":44,"number":45,"year":46,"session":10},"nurse-114-2-medical-surgical-043","陳太太，58 歲，近期被診斷罹患阿茲海默症，目前出現情緒不穩、易怒，上街買東西會忘了付錢，常常忘記梳洗就直接上床睡覺，也經常懷疑兒子在家偷錢，根據狀況，目前其處在阿茲海默症那一期？",43,114,{"webId":48,"stem":49,"number":50,"year":51,"session":30},"nurse-106-1-medical-surgical-041","有關乳癌之敘述，下列何者錯誤？",41,106,{"webId":53,"stem":54,"number":55,"year":56,"session":10},"nurse-107-2-medical-surgical-005","有關抗癲癇藥物 dilantin 之敘述，下列何者正確？",5,107,{"webId":58,"stem":59,"number":60,"year":61,"session":10},"nurse-108-2-medical-surgical-039","B 型肝炎帶原者接受化學治療時之護理指導，下列何者錯誤？",39,108,"2026-09-04",1788510754859]