[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-115-2-medical-surgical-004":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":34,"lastmod":63},"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-004","nurse-115-2-medical-surgical-004",115,2,4,"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？",{"A":14,"B":15,"C":16,"D":17},"包括睜眼、瞳孔及語言反應三部分","疼痛刺激後，病人睜開眼睛，睜眼反應給 3 分","疼痛刺激後，病人發出無法理解的呻吟聲，語言反應給 3 分","接受氣管切開術無法發聲時，語言反應以「T」表示","D",null,[],"本題考點是格拉斯哥昏迷量表的組成與計分細節。依量表定義,GCS 由睜眼反應(E,1 至 4 分)、語言反應(V,1 至 5 分)與運動反應(M,1 至 6 分)三部分構成;當病人因氣管內管或氣管切開術無法發聲時,語言項無從評分,依慣例以英文字母 T(tube)標示,故選 D。A 錯在把瞳孔反應算進 GCS,瞳孔大小與對光反應屬另一套神經學評估項目。B 錯在分數,疼痛刺激才睜眼是睜眼反應 2 分,呼喚就睜眼才給 3 分。C 錯在無法理解的呻吟聲屬語言反應 2 分,說出不適當的用字才是 3 分。","完整計分口訣可分三軸背:睜眼由自動睜眼 4、呼喚睜眼 3、疼痛睜眼 2、無反應 1;語言由說話清楚有定向感 5、答話混亂 4、不適當用字 3、無法理解的聲音 2、無反應 1;運動由依指令動作 6、疼痛能定位 5、疼痛回縮 4、異常屈曲(去皮質)3、異常伸展(去大腦)2、無反應 1。滿分 15、最低 3,總分 8 分以下定義為昏迷,通常需保護呼吸道。無法評分時的標註慣例:眼睛腫脹無法睜開記 C(closed),語言因插管記 T,肢體固定或截肢記 NT。",[24,27,30,32],{"term":25,"count":26},"意識評估",3,{"term":28,"count":29},"格拉斯哥昏迷量表",1,{"term":31,"count":29},"睜眼反應計分",{"term":33,"count":29},"語言反應計分",[35,39,44,48,53,58],{"webId":36,"stem":37,"number":38,"year":9,"session":10},"nurse-115-2-medical-surgical-005","當腦瘤病人出現噴射性嘔吐時，腫瘤最可能壓迫到下列那一個部位？",5,{"webId":40,"stem":41,"number":42,"year":43,"session":29},"nurse-106-1-medical-surgical-051","在正常生理狀態下，下列何者為刺激呼吸中樞而影響呼吸之主要物質？",51,106,{"webId":45,"stem":46,"number":47,"year":43,"session":10},"nurse-106-2-medical-surgical-065","有關甲狀腺機能亢進病人服用碘製劑之注意事項，下列何者正確？",65,{"webId":49,"stem":50,"number":51,"year":52,"session":29},"nurse-108-1-medical-surgical-023","有關鼻竇炎之敘述，下列何者錯誤？",23,108,{"webId":54,"stem":55,"number":56,"year":57,"session":29},"nurse-109-1-medical-surgical-067","有關糖尿病的藥物治療之敘述，下列何者正確？",67,109,{"webId":59,"stem":60,"number":61,"year":62,"session":10},"nurse-110-2-medical-surgical-021","有關全髖關節置換術後病人之護理指導，下列何者錯誤？",21,110,"2026-08-06",1787299036977]