[{"data":1,"prerenderedAt":62},["ShallowReactive",2],{"q-nurse-115-2-medical-surgical-001":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":33,"lastmod":61},"內外科護理學","medical-surgical",{"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":26},"nurse-115-2-內外科護理學-001","nurse-115-2-medical-surgical-001",115,2,1,"腦下垂體腫瘤病人接受經蝶骨腫瘤切除術後第 4 天，持續有流鼻水、頭痛現象，下列處置之敘述何者正確？",{"A":14,"B":15,"C":16,"D":17},"手術傷口是在頭部頂葉及顳葉處，須每日給與換藥","給與減少流鼻水藥物，以免咳嗽造成顱內壓升高","教導病人不要擤鼻涕，目前不宜下床活動","可從鼻腔進行抽吸，以促進呼吸道暢通","C",null,[],"本題考點是經蝶骨腦下垂體腫瘤切除術後辨識腦脊髓液(CSF)漏。手術路徑經鼻腔與蝶骨進入顱底鞍區,術後第 4 天仍持續流鼻水並伴頭痛,依 CSF 漏的典型表現(清澈水狀鼻液、姿勢性頭痛)須先假設是腦脊髓液外漏,護理重點在避免任何升高顱內壓或干擾鼻腔傷口癒合的動作,因此不擤鼻涕並暫時限制下床活動,選 C。A 錯在解剖位置,傷口在鼻腔與蝶骨鞍區,不在頂葉、顳葉,也不做每日頭部換藥。B 錯在把 CSF 漏當成上呼吸道分泌物處理,止鼻水藥無法封閉漏口,反而延誤發現。D 錯在鼻腔抽吸會破壞縫合處並讓細菌上行造成腦膜炎,是此術式的明確禁忌。","CSF 漏的床邊辨識法:鼻液滴在紗布上呈中央血漬、外圈清澈的暈環徵象(halo sign),試紙測葡萄糖呈陽性(單純鼻腔分泌物不含葡萄糖),病人常主訴有鹹味液體順咽喉流下。此術式術後三不原則好記:不擤鼻、不用吸管吸吮、暫不刷上排牙齒,並抬高床頭約 30 度、避免咳嗽與用力解便,因這些動作都會瞬間升高顱內壓而撐開漏口。另一組延伸考點是腦下垂體後葉受擾導致抗利尿激素不足的尿液崩症,表現為大量低比重尿與高血鈉,故術後需嚴密記錄輸入輸出量與尿比重。",[24,27,29,31],{"term":25,"count":26},"腦脊髓液漏",4,{"term":28,"count":10},"經蝶骨腦下垂體切除術",{"term":30,"count":11},"顱內壓上升預防",{"term":32,"count":11},"術後鼻腔照護",[34,37,42,46,51,56],{"webId":35,"stem":36,"number":10,"year":9,"session":10},"nurse-115-2-medical-surgical-002","有關阿茲海默症（Alzheimer’s disease）的病因病理，下列敘述何者正確？",{"webId":38,"stem":39,"number":40,"year":41,"session":11},"nurse-106-1-medical-surgical-048","病人手部有尺側偏斜及近端指關節過度伸展變形，下列何者為其最可能之診斷？",48,106,{"webId":43,"stem":44,"number":45,"year":41,"session":10},"nurse-106-2-medical-surgical-062","正常成年人，若膀胱容積壓力正常，最大尿流速低於下列何者即顯示尿道出口有阻塞現象？",62,{"webId":47,"stem":48,"number":49,"year":50,"session":11},"nurse-108-1-medical-surgical-020","有關骨質疏鬆症與骨密度檢查的敘述，下列何者錯誤？",20,108,{"webId":52,"stem":53,"number":54,"year":55,"session":11},"nurse-109-1-medical-surgical-064","甲狀腺機能亢進之臨床表徵，下列何者正確？①月經減少或停經 ②深肌腱反射減弱 ③指甲遠心端鬆脫 ④皮膚潮紅乾裂 ⑤脛前黏液水腫 ⑥指尖有刺麻感",64,109,{"webId":57,"stem":58,"number":59,"year":60,"session":10},"nurse-110-2-medical-surgical-018","有關腔隙症候群的處置，下列何者正確？",18,110,"2026-08-06",1787299036951]