[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-115-2-medical-surgical-003":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":33,"lastmod":62},"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":10},"nurse-115-2-內外科護理學-003","nurse-115-2-medical-surgical-003",115,2,3,"有關成人腦室外引流系統裝置的護理措施，下列敘述何者錯誤？",{"A":14,"B":15,"C":16,"D":17},"病人改變姿勢時應重新核對零點","在病人平躺時，引流裝置的零點對齊病人鼻尖","若病人有咳嗽、解便、移動等活動時暫不測量顱內壓","此系統可用來監測顱內壓及引流腦脊髓液","B",null,[],"本題考點是腦室外引流(EVD)系統的零點定位。依壓力測量原理,引流系統零點必須對齊腦室(Monro 孔)的體表投影,平躺時以外耳道(耳屏)高度為基準,而非鼻尖,故錯誤敘述為 B。A 正確,零點是相對於體位的參考點,姿勢一改變靜水壓即隨之改變,必須重新校對,否則引流過多會造成腦室塌陷、引流不足則使顱內壓上升。C 正確,咳嗽、用力解便、翻身移動都會瞬間拉高胸腔內壓與顱內壓,此時讀值不具代表性,應待病人安靜平躺再測。D 正確,此系統兼具監測顱內壓與引流腦脊髓液以降壓的雙重功能。","零點定位的意義在於整套引流壓力設定都以它為基準:引流袋滴室高度(例如設在零點上方 10 至 15 cmH2O)決定顱內壓超過多少才開始排出腦脊髓液,零點一旦偏移,實際引流閾值就整體偏高或偏低。實務延伸:移動病人、抬降床頭、翻身前先夾管,復位並重新歸零後再開放;每小時記錄引流量、顏色與波動,量突增要懷疑零點過低或導管位置改變,量驟減或無波動要懷疑血塊阻塞、導管扭折。引流液由清澈轉混濁或病人出現發燒、頸部僵硬,則須警覺導管相關腦膜炎。",[24,26,28,31],{"term":25,"count":10},"腦室外引流",{"term":27,"count":10},"顱內壓監測",{"term":29,"count":30},"Monro 孔零點定位",1,{"term":32,"count":30},"靜水壓原理",[34,38,43,47,52,57],{"webId":35,"stem":36,"number":37,"year":9,"session":10},"nurse-115-2-medical-surgical-004","有關以格拉斯哥昏迷量表（GCS）測量病人意識程度變化之敘述，下列何者正確？",4,{"webId":39,"stem":40,"number":41,"year":42,"session":30},"nurse-106-1-medical-surgical-050","下列何者屬於免疫複合體性之過敏反應？",50,106,{"webId":44,"stem":45,"number":46,"year":42,"session":10},"nurse-106-2-medical-surgical-064","有關雙胍類降血糖藥物 Metformin（Glucophage）之敘述，下列何者正確？",64,{"webId":48,"stem":49,"number":50,"year":51,"session":30},"nurse-108-1-medical-surgical-022","有關視網膜剝離手術後病人護理措施之敘述，下列何者錯誤？",22,108,{"webId":53,"stem":54,"number":55,"year":56,"session":30},"nurse-109-1-medical-surgical-066","有關高滲透壓高血糖狀態（HHS）之敘述，下列何者正確？",66,109,{"webId":58,"stem":59,"number":60,"year":61,"session":10},"nurse-110-2-medical-surgical-020","有關痛風性關節炎病人的護理指導，下列何者正確？",20,110,"2026-08-06",1787299036967]