[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-114-1-medical-surgical-032":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-114-1-內外科護理學-032","nurse-114-1-medical-surgical-032",114,1,32,"病人因車禍送到急診，身體評估出現下列何者時，應懷疑可能有氣胸？",{"A":14,"B":15,"C":16,"D":17},"一側聽不到呼吸音或呼吸音減弱","二側肺葉有喘鳴音","二側肺葉於吸氣時聽到囉音","一側肺葉叩診出現濁音","A",null,[],"本題考點在於外傷性氣胸的身體評估徵象。依氣胸的病生理，肋膜腔積氣使該側肺塌陷、空氣傳導受阻，故患側呼吸音消失或明顯減弱，A正確為答案。B兩側肺葉喘鳴音反映廣泛下呼吸道阻塞（如氣喘），非氣胸單側表現；C兩側吸氣期囉音提示肺泡有液體（如肺水腫、肺炎），與積氣性質相反；D患側叩診濁音代表實質化或積液，而氣胸積氣時叩診反而為過度反響（鼓音），故B、C、D皆與氣胸表現不符。","氣胸的評估口訣是「患側呼吸音減弱＋叩診過度反響」，因氣體佔據肋膜腔並壓迫肺實質。張力性氣胸更會出現氣管偏移向健側、頸靜脈怒張與血壓下降，屬需立即減壓的急症。相對地，血胸或肋膜積液則叩診濁音、呼吸音減弱。車禍胸部鈍傷評估時，聽診加叩診的組合可快速鑑別是積氣還是積液。",[24,27,29,31],{"term":25,"count":26},"氣胸",3,{"term":28,"count":26},"患側呼吸音減弱",{"term":30,"count":26},"叩診過度反響音",{"term":32,"count":33},"肋膜腔積氣",2,[35,39,43,48,53,58],{"webId":36,"stem":37,"number":38,"year":9,"session":10},"nurse-114-1-medical-surgical-033","有關急性呼吸窘迫症候群（ARDS）之敘述，下列何者正確？",33,{"webId":40,"stem":41,"number":42,"year":9,"session":26},"nurse-114-3-medical-surgical-029","有關改善過敏反應的生活指導，下列敘述何者最適當？",29,{"webId":44,"stem":45,"number":46,"year":47,"session":33},"nurse-115-2-medical-surgical-023","有關癌症病人出現食慾不振之護理措施，下列何者最適當？",23,115,{"webId":49,"stem":50,"number":51,"year":52,"session":10},"nurse-107-1-medical-surgical-011","有關潰瘍性結腸炎與區域性結腸炎之比較，下列何者錯誤？",11,107,{"webId":54,"stem":55,"number":56,"year":57,"session":10},"nurse-108-1-medical-surgical-055","觀察到胸腔水下引流的水封瓶內持續有小量氣泡時之處置，下列何者正確？",55,108,{"webId":59,"stem":60,"number":61,"year":62,"session":33},"nurse-109-2-medical-surgical-009","有關闌尾炎身體評估檢查的結果，下列何者正確？①墨菲氏徵象（Murphy’s sign） ②麥氏點（McBurney’s point）壓痛 ③普氏徵象（Psoas sign） ④閉孔肌徵象（obturator sign）",9,109,"2026-09-04",1788510757467]