[{"data":1,"prerenderedAt":66},["ShallowReactive",2],{"q-nurse-114-3-fundamental-nursing-005":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":36,"lastmod":65},"基本護理學與護理行政","fundamental-nursing","基本護理學(包括護理原理、護理技術)與護理行政",{"id":8,"webId":9,"year":10,"session":11,"subject":4,"number":12,"stem":13,"options":14,"answer":19,"answerNote":20,"images":21,"explanation":22,"explanationDeep":23,"topics":24,"freq":27},"nurse-114-3-基本護理學與護理行政-005","nurse-114-3-fundamental-nursing-005",114,3,5,"有關護理評估，下列敘述何者最適當？",{"A":15,"B":16,"C":17,"D":18},"是護理過程的最後一個步驟，目的在診斷確立後加以驗證","蒐集病人過去及現在的身心靈、社會、認知及發展等健康資料","嚴重腦損傷且無法表達的病人對疼痛的哭泣反應，視為初級資料來源（primary source）","次級資料來源（secondary source）包含醫療專業照顧者的主觀意見","B",null,[],"本題考點在於護理評估此一步驟的正確定義。依護理過程的架構，評估是有系統地蒐集病人過去與現在的身、心、靈、社會、認知及發展等健康資料，作為診斷與計畫的基礎，(B)敘述正確，故選B。(A)評估是護理過程的第一個步驟而非最後一步(最後為評值);(C)嚴重腦損傷無法表達者的哭泣反應屬觀察所得的客觀資料，病人本人才是初級資料來源，敘述混淆;(D)次級資料來源指病人以外(如家屬、病歷、醫療團隊)提供的資料，不應以『主觀意見』界定，故均不適當。","護理過程五步驟為評估、診斷、計畫、執行、評值(ADPIE)，評估在前、評值在後，兩者中文相近但位置與目的不同。資料來源分初級(病人本人)與次級(家屬、其他醫療人員、病歷、文獻);又分主觀(病人主訴)與客觀(觀察、測量、檢驗)。記憶要訣:『初級=當事人、次級=旁人與紀錄』與『主觀=說出來、客觀=看得到測得到』兩組概念常被合併出題，須分開判斷。",[25,28,31,34],{"term":26,"count":27},"護理評估",15,{"term":29,"count":30},"護理過程",11,{"term":32,"count":33},"ADPIE步驟",1,{"term":35,"count":33},"初級與次級資料來源",[37,41,46,51,56,61],{"webId":38,"stem":39,"number":40,"year":10,"session":11},"nurse-114-3-fundamental-nursing-006","下列何者屬於主觀資料？",6,{"webId":42,"stem":43,"number":44,"year":45,"session":44},"nurse-115-2-fundamental-nursing-002","依據民國 112 年之護理人員法各項條文中，對於護理人員執業之規定，下列何者錯誤？",2,115,{"webId":47,"stem":48,"number":49,"year":50,"session":33},"nurse-106-1-fundamental-nursing-046","病人長時間採半坐臥姿勢，身體受壓處不包括下列那一部位？",46,106,{"webId":52,"stem":53,"number":54,"year":55,"session":44},"nurse-107-2-fundamental-nursing-004","有關內科無菌洗手原則之敘述，下列何者正確？",4,107,{"webId":57,"stem":58,"number":59,"year":60,"session":44},"nurse-108-2-fundamental-nursing-048","鄭先生接受腸道手術切除腫瘤，術後第三天排氣且開始嘗試由口進食，下列何者是此時最適當的飲食型態？",48,108,{"webId":62,"stem":63,"number":44,"year":64,"session":33},"nurse-110-1-fundamental-nursing-002","臨床上常遇到布類有舊血漬沾染，下列何者對於清除舊血漬的效果最佳？",110,"2026-09-04",1788510761446]