[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-115-1-fundamental-nursing-007":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":35,"lastmod":64},"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-115-1-基本護理學與護理行政-007","nurse-115-1-fundamental-nursing-007",115,1,7,"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？",{"A":15,"B":16,"C":17,"D":18},"收集病人的主觀及客觀資料，以確立疼痛問題","將急性疼痛列為必須優先處理的護理問題","擬定給止痛藥後，病人疼痛降至2分的護理目標","計畫協助病人採取半坐臥式的護理活動","A",null,[],"本題考點為護理過程五步驟的階段區辨。護理過程依序為評估、診斷、計畫、執行、評值;「收集病人主觀及客觀資料,以確立疼痛問題」屬於評估與診斷階段的工作,不屬於計畫階段,故A為本題答案(不包括者)。計畫階段的內容包括:排定護理問題的優先順序(B,急性疼痛依Maslow需求層級屬生理需求,列為優先)、設定具體可測量的護理目標(C,給止痛藥後疼痛降至2分,符合可評值原則)、擬定護理活動(D,協助採半坐臥式以減輕腹部切口張力),三者皆屬計畫階段內容。","計畫階段三部曲:「排序→立目標→訂措施」。優先順序依Maslow需求層級與問題危急性排定;目標書寫符合SMART原則(具體、可測量、可達成、實際、有時限),並以病人為主詞;措施須寫明做什麼、多久做一次、如何做。與評估(收集資料)、診斷(確立問題)、執行(實施措施)、評值(比對目標達成度)清楚切分——「確立問題」四個字出現就是診斷階段,是考題最愛的混淆點。",[25,28,31,33],{"term":26,"count":27},"護理過程五步驟",5,{"term":29,"count":30},"Maslow 需求層級",2,{"term":32,"count":11},"計畫階段內容",{"term":34,"count":11},"SMART 目標",[36,40,45,49,54,59],{"webId":37,"stem":38,"number":39,"year":10,"session":11},"nurse-115-1-fundamental-nursing-008","王先生訴呼吸喘，聽診雙肺呈濕囉音，叩診肺呈濁音，觸診下肢水腫2＋。上述資料何者屬於症狀（symptoms）？",8,{"webId":41,"stem":42,"number":43,"year":44,"session":11},"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？",4,106,{"webId":46,"stem":47,"number":48,"year":44,"session":30},"nurse-106-2-fundamental-nursing-018","承上題，在給予藥物時，下列何者正確？",18,{"webId":50,"stem":51,"number":52,"year":53,"session":30},"nurse-107-2-fundamental-nursing-056","有關痰液常規檢查之敘述，下列何者錯誤？",56,107,{"webId":55,"stem":56,"number":57,"year":58,"session":11},"nurse-109-1-fundamental-nursing-020","下列護理紀錄書寫，何者較為精確？",20,109,{"webId":60,"stem":61,"number":62,"year":63,"session":11},"nurse-110-1-fundamental-nursing-054","有關臨終病人的生理變化，下列何者正確？",54,110,"2026-08-06",1787299088060]