[{"data":1,"prerenderedAt":66},["ShallowReactive",2],{"q-nurse-115-2-maternal-pediatric-049":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":35,"lastmod":65},"產兒科護理學","maternal-pediatric",{"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-115-2-產兒科護理學-049","nurse-115-2-maternal-pediatric-049",115,2,49,"蘇小妹，3 歲，開顱手術後第 2 天，有關評估顱內壓上升的症狀，下列何項評估不適當？",{"A":14,"B":15,"C":16,"D":17},"前囟門膨出","血壓上升","意識改變","呼吸變慢","A",null,[],"本題考點在於評估顱內壓上升時必須配合病童年齡的解剖條件。前囟門通常在十二到十八個月大即已閉合,三歲病童已無前囟門可觀察其膨出,故 A 的評估不適當。B 適當,顱內壓上升到一定程度會出現庫辛反應,表現為血壓上升伴隨脈搏變慢。C 適當,意識程度改變是顱內壓上升最早且最敏感的指標。D 適當,腦幹受壓迫時呼吸型態改變、變慢甚至不規則,與血壓上升、心跳變慢並列為庫辛三徵。","延伸病生理:顱腔容積固定,依 Monro-Kellie 假說,腦組織、血液與腦脊髓液三者任一增加都須以其他成分代償,代償耗盡後顱內壓便急速上升。嬰兒因囟門與骨縫未閉合可額外代償,故表徵不同:囟門膨出、頭圍異常增加、高音調哭聲、落日眼與頭皮靜脈擴張;較大兒童則以頭痛、清晨噁心嘔吐、視力改變、意識程度下降與瞳孔對光反應變化為主。庫辛三徵屬晚期表現,出現時已接近腦幹受壓與腦疝,不能當作早期篩檢依據。開顱術後護理原則包含床頭抬高約三十度、頭頸維持中線避免屈頸或旋轉、避免用力解便與抽吸過久造成的類 Valsalva 動作、集中護理減少刺激、監測體溫與電解質。可連結概念:昏迷指數評估、腦水腫與滲透性脫水治療、腦疝症候群。",[24,26,28,30,33],{"term":25,"count":10},"前囟門閉合時間",{"term":27,"count":10},"顱內壓上升徵象",{"term":29,"count":10},"開顱術後護理",{"term":31,"count":32},"庫辛三徵",1,{"term":34,"count":32},"意識改變為早期指標",[36,40,45,50,55,60],{"webId":37,"stem":38,"number":39,"year":9,"session":10},"nurse-115-2-maternal-pediatric-050","小富，17 歲，因左側股骨骨折須以石膏固定，有關小富所需要的護理，下列敘述何者正確？",50,{"webId":41,"stem":42,"number":43,"year":44,"session":10},"nurse-106-2-maternal-pediatric-016","產婦於第三產程後，依醫囑施打宮縮藥物（Methergine ○ R , Ergonovine）。護理師於下列何種情況需停止給藥？",16,106,{"webId":46,"stem":47,"number":48,"year":49,"session":32},"nurse-107-1-maternal-pediatric-030","承上題，下列何者可能為造成上述情形的原因？",30,107,{"webId":51,"stem":52,"number":53,"year":54,"session":32},"nurse-108-1-maternal-pediatric-068","有關氧氣治療的敘述，下列何者正確？",68,108,{"webId":56,"stem":57,"number":58,"year":59,"session":10},"nurse-109-2-maternal-pediatric-032","子癇前症之症狀，下列何者錯誤？",32,109,{"webId":61,"stem":62,"number":63,"year":64,"session":10},"nurse-110-2-maternal-pediatric-066","30 週早產之男嬰，出生體重 1,500 公克，診斷開放性動脈導管（patent ductus arteriosus），以 Indomethacin 靜脈注射治療，下列敘述何者正確？",66,110,"2026-08-06",1787299007434]