[{"data":1,"prerenderedAt":66},["ShallowReactive",2],{"q-nurse-115-1-fundamental-nursing-006":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":35,"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":11},"nurse-115-1-基本護理學與護理行政-006","nurse-115-1-fundamental-nursing-006",115,1,6,"有關紀錄書寫的原則，下列敘述何者錯誤？",{"A":15,"B":16,"C":17,"D":18},"記錄病人的抱怨內容時應標註「病人主述」，以便能區辨非家屬所言","病人的治療和反應皆應正確完整記錄，必要時其可作為法律證明文件","針對病人的護理目標和護理措施的擬定應具體可行、避免過於理想化","對執行護理措施後仍無法緩解的症狀，除了紀錄之外還需要報告醫師","A",null,[],"本題考點在護理紀錄中主觀資料的書寫原則。病人的抱怨屬主觀資料,書寫重點是以引號逐字引述病人原話並註明陳述者,家屬代訴的內容同樣要完整記錄,只需標明是家屬代訴,並不是要把家屬所言排除或視為次級資料;A 把標註「病人主述」的目的說成用來區辨非家屬所言,等於把註記當成篩除家屬資料的手段,方向錯誤,故選 A。B 正確,治療與病人反應須正確完整記錄,紀錄具法律證據力。C 正確,護理目標與措施要具體、可測量、可執行,過於理想化將無法評值。D 正確,措施後症狀未緩解代表評值未達成,除記錄外需向醫師報告以修正治療計畫。","把主客觀資料的處理原則拆開記:主觀資料來自病人或家屬的陳述,寫法是引號直接引述原話並註明來源(誰說的),避免護理人員自行推論改寫,例如寫「我從昨天晚上開始右下腹一直悶痛」而不是寫「病人腹痛難耐」;客觀資料則是可觀察、可測量的事實與檢查數值。紀錄的一般原則常考:及時、正確、完整、客觀、依時間序、使用機構核可的縮寫、錯誤處畫單線並註記更正者與時間、不留空白行、不使用鉛筆或修正液塗改。護理過程紀錄格式可對比 SOAPIE(主觀、客觀、評估、計畫、執行、評值)與焦點紀錄 DAR(資料、行動、反應)。可延伸複習:電子病歷的簽章與稽核軌跡、口頭醫囑的覆誦與補記規則。",[25,27,29,31,33],{"term":26,"count":11},"主觀資料引述原則",{"term":28,"count":11},"護理紀錄書寫原則",{"term":30,"count":11},"紀錄的法律證據力",{"term":32,"count":11},"護理目標具體可行",{"term":34,"count":11},"評值與再報告",[36,40,45,50,55,60],{"webId":37,"stem":38,"number":39,"year":10,"session":11},"nurse-115-1-fundamental-nursing-007","急性膽囊炎開腹手術後、生命徵象穩定的病人，擬定其護理計畫（nursing plan）階段內容，不包括下列何者？",7,{"webId":41,"stem":42,"number":43,"year":44,"session":11},"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？",3,106,{"webId":46,"stem":47,"number":48,"year":44,"session":49},"nurse-106-2-fundamental-nursing-017","丁太太昨日接受剖腹手術，術後 24 小時仍未排氣，因此醫囑予 Dulcolax 2# Supp（10 mg）q4h prn。丁太太之醫囑內容為何？",17,2,{"webId":51,"stem":52,"number":53,"year":54,"session":49},"nurse-107-2-fundamental-nursing-055","尤先生，66 歲，診斷慢性阻塞性肺疾病（chronic obstructive pulmonary disease, COPD），因呼吸喘、發燒，由急診送入病房，其立即性的入院護理包括：①監測生命徵象 ②病房環境介紹 ③測量身高體重 ④測量血氧飽和度 ⑤教導呼叫鈴使用 ⑥教導檢體收集方法與檢體放置處",55,107,{"webId":56,"stem":57,"number":58,"year":59,"session":11},"nurse-109-1-fundamental-nursing-019","張先生因術後傷口疼痛面露愁容，護理人員評估其疼痛的時間、性質、部位及影響因素等，這屬於何種護理功能？",19,109,{"webId":61,"stem":62,"number":63,"year":64,"session":11},"nurse-110-1-fundamental-nursing-053","有關安寧緩和療護之敘述，下列何者正確？",53,110,"2026-08-06",1787299088055]