[{"data":1,"prerenderedAt":62},["ShallowReactive",2],{"q-nurse-114-3-medical-surgical-005":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":32,"lastmod":61},"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-114-3-內外科護理學-005","nurse-114-3-medical-surgical-005",114,3,5,"有關單純頭部損傷病人，其顱內壓升高非代償期初期階段的徵象，下列敘述何者正確？",{"A":14,"B":15,"C":16,"D":17},"呼吸及脈搏變慢，且血壓下降","呼吸變快、瞳孔放大，且血壓上升","脈搏變慢而有力，且血壓上升","呼吸不規則及脈搏變弱、快，且血壓下降","C",null,[],"本題考點在於顱內壓升高失代償初期的生命徵象變化。考點在於庫欣三徵(Cushing's triad):顱內壓上升壓迫腦幹時,身體代償以升高血壓維持腦部灌流,並反射性使脈搏變慢而有力(洪脈),同時呼吸型態改變,故初期典型為脈搏變慢而有力且血壓上升,選 C。A 血壓下降不符合升壓代償。B 呼吸變快、瞳孔放大且血壓上升的組合並非庫欣反應典型描述。D 呼吸不規則、脈搏變弱且快、血壓下降屬晚期腦幹衰竭或休克前兆,而非非代償初期。因此最符合的是 C。","庫欣三徵=收縮壓升高使脈壓變大、心跳過緩、呼吸型態異常(如 Cheyne-Stokes),反映顱內壓危急壓迫腦幹的代償反應,是延遲且不祥的徵象。臨床上更早期常見的是意識改變、頭痛、噴射狀嘔吐與瞳孔變化。當進展到脈搏轉弱而快、血壓下降時,代表代償失敗、腦幹功能瀕臨衰竭。記憶:壓高、心慢、呼吸怪三合一即顱內壓危象。",[24,27,30],{"term":25,"count":26},"顱內壓升高",11,{"term":28,"count":29},"庫欣三徵 Cushing's triad",1,{"term":31,"count":29},"腦部灌流代償",[33,37,42,47,52,57],{"webId":34,"stem":35,"number":36,"year":9,"session":10},"nurse-114-3-medical-surgical-006","有關小腸阻塞的臨床表徵與評估，下列敘述何者最適當？①劍突下可見強蠕動波 ②嘔吐物含糞便臭味 ③鈉、鉀、氯值降低 ④阻塞早期腸蠕動音消失",6,{"webId":38,"stem":39,"number":40,"year":41,"session":40},"nurse-115-2-medical-surgical-002","有關阿茲海默症（Alzheimer’s disease）的病因病理，下列敘述何者正確？",2,115,{"webId":43,"stem":44,"number":45,"year":46,"session":29},"nurse-106-1-medical-surgical-046","預防疥瘡再發及傳染他人的護理指導，下列何者錯誤？",46,106,{"webId":48,"stem":49,"number":50,"year":51,"session":40},"nurse-107-2-medical-surgical-004","腦膜受刺激會出現下列何種現象？",4,107,{"webId":53,"stem":54,"number":55,"year":56,"session":40},"nurse-108-2-medical-surgical-048","有關類風溼性關節炎流行病學之敘述，下列何者錯誤？",48,108,{"webId":58,"stem":59,"number":40,"year":60,"session":29},"nurse-110-1-medical-surgical-002","多發性硬化症（multiple sclerosis; MS）使用 Cyclophosphamide 藥物治療之最主要目的，下列何者正確？",110,"2026-09-04",1788510761888]