[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-115-1-psychiatric-community-022":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":32,"lastmod":62},"精神科與社區衛生護理學","psychiatric-community",{"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":10},"nurse-115-1-精神科與社區衛生護理學-022","nurse-115-1-psychiatric-community-022",115,1,22,"承上題，有關身體約束的相關護理措施，下列敘述何者正確？",{"A":14,"B":15,"C":16,"D":17},"依照醫囑執行約束，不需簽署同意書","約束中應觀察四肢之血液循環及臉部膚色、溫度與感覺","為保護病人，不可等到足夠人力，需立即執行約束，以免產生嚴重傷害","在執行約束之後應協助病人補充大量水分","B",null,[],"本題考點是身體約束期間的護理監測。約束最主要的併發症是肢體末梢循環障礙與神經壓迫,故約束中應定時觀察四肢的血液循環(膚色、溫度、脈動、感覺)及臉部膚色,並確認約束帶鬆緊適中(以可容納一至二指為原則),B正確。A錯:執行約束除須醫囑外,仍應告知病人與家屬,並依規定簽署同意書與完整記錄;C錯:約束前必須集結足夠人力(通常四至五人以上)以確保病人與工作人員安全,人力不足貿然執行反而容易造成傷害;D錯:約束期間應定時提供水分與如廁協助,但並無執行後「補充大量水分」的常規,該敘述無依據。","約束照護的監測清單可用「循環、皮膚、姿位、需求、解除」五字訣:每15分鐘看末梢循環與感覺、檢查皮膚完整與約束帶鬆緊(容一至二指)、維持功能性姿位並定時活動肢體、滿足進食飲水如廁等基本需求、持續評估是否達解除條件並儘早解除。團隊執行時應有明確分工(一人指揮、四肢各有專人),行動迅速一致以縮短對抗時間。文件面須記錄:誘發行為、曾嘗試的替代措施、醫囑、起訖時間與每次觀察結果,這是照護品質與法律防護的雙重依據。",[24,26,28,30],{"term":25,"count":10},"約束肢體循環監測",{"term":27,"count":10},"約束帶鬆緊原則(容一至二指)",{"term":29,"count":10},"約束執行人力配置",{"term":31,"count":10},"同意書與護理紀錄",[33,37,42,47,52,57],{"webId":34,"stem":35,"number":36,"year":9,"session":10},"nurse-115-1-psychiatric-community-023","張太太因先生車禍意外過世出現激動不安、捶打家人，遂被帶至急診救治。依據卡普蘭（Caplan.）危機理論，張太太目前處於危機發展過程的那一期？",23,{"webId":38,"stem":39,"number":40,"year":41,"session":10},"nurse-106-1-psychiatric-community-019","丁小姐使用鋰鹽治療，血中鋰鹽濃度已達到 1.2 mEq\u002FL，護理師應優先採取下列何項措施？",19,106,{"webId":43,"stem":44,"number":45,"year":41,"session":46},"nurse-106-2-psychiatric-community-033","有關自殺的敘述，下列何者錯誤？",33,2,{"webId":48,"stem":49,"number":50,"year":51,"session":46},"nurse-107-2-psychiatric-community-071","李大明，20 歲，平地原住民男性，平時有抽菸、嚼檳榔、飲酒習慣，第一次參加社區健康篩檢活動，他可以參加下列何項篩檢項目？",71,107,{"webId":53,"stem":54,"number":55,"year":56,"session":46},"nurse-109-2-psychiatric-community-035","林護理師為協助病人返家居住，進行家庭評估與提供服務的內容，下列措施何者最適當？",35,109,{"webId":58,"stem":59,"number":60,"year":61,"session":46},"nurse-110-2-psychiatric-community-069","有關理想的校園健康環境，下列何者錯誤？",69,110,"2026-08-06",1787299089922]