[{"data":1,"prerenderedAt":47},["ShallowReactive",2],{"q-nurse-114-3-fundamental-nursing-005":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":24},"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,"freq":23},"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。",1,[25,29,33,36,40,43],{"webId":26,"stem":27,"number":23,"year":28,"session":23},"nurse-106-1-fundamental-nursing-001","下列何者為預防院內感染最經濟有效的方法？",106,{"webId":30,"stem":31,"number":32,"year":28,"session":23},"nurse-106-1-fundamental-nursing-002","下列那一種健康問題會導致體溫過高？",2,{"webId":34,"stem":35,"number":11,"year":28,"session":23},"nurse-106-1-fundamental-nursing-003","王先生因腦血管損傷住院中，下列何種灌注溶液不適合王先生使用？",{"webId":37,"stem":38,"number":39,"year":28,"session":23},"nurse-106-1-fundamental-nursing-004","醫囑為 Acetaminophen 1 tab q6h p.r.n. if BT≧39℃之含義，下列敘述何者正確？",4,{"webId":41,"stem":42,"number":12,"year":28,"session":23},"nurse-106-1-fundamental-nursing-005","測量 H5N1 流感病毒感染病人生命徵象時，下列何項防護設備較不必要？",{"webId":44,"stem":45,"number":46,"year":28,"session":23},"nurse-106-1-fundamental-nursing-006","林小姐因中風導致右側肢體偏癱，住院期間有關病人之安全，下列敘述何者錯誤？",6,1783840779105]