[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-115-2-medical-surgical-020":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":35,"lastmod":64},"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-020","nurse-115-2-medical-surgical-020",115,2,20,"有關下肢深部靜脈栓塞之症狀與評估，下列何者正確？",{"A":14,"B":15,"C":16,"D":17},"下肢冰冷蒼白、霍曼氏徵象（Homan’s sign）陽性","間歇性跛行、艾倫試驗（Allen’s test）陽性","下肢發紅、霍曼氏徵象（Homan’s sign）陽性","下肢水腫、艾倫試驗（Allen’s test）陽性","C",null,[],"本題考點是下肢深部靜脈栓塞與動脈缺血徵象的區辨。依病生理,靜脈回流受阻使血液滯留、微血管靜水壓上升,患肢出現腫脹、發紅、溫熱與壓痛,並可見表淺靜脈擴張;霍曼氏徵象即被動背屈足踝時引起小腿後側疼痛,傳統上作為深部靜脈栓塞的參考徵象,故選 C。A 錯在冰冷蒼白與無脈是動脈血流阻斷的表現,與靜脈栓塞的溫熱發紅方向相反。B 錯在間歇性跛行屬下肢動脈阻塞性疾病的典型症狀,且艾倫試驗是評估手部橈動脈與尺動脈的循環,與下肢無關。D 的水腫雖符合,但同樣誤用艾倫試驗。","血栓形成的三要素(Virchow 三角)是所有預防措施的根:血流滯緩(久臥、長途飛行、術後不動)、血管內壁損傷(外傷、置放導管)、血液凝固性增加(懷孕、口服避孕藥、惡性腫瘤、脫水)。要知道霍曼氏徵象的敏感度與特異度都不高,不能單憑它診斷,確診靠 D-dimer 篩檢加靜脈加壓超音波。護理重點包括抬高患肢促進回流、不按摩或熱敷患肢以免血栓脫落、依醫囑使用抗凝藥物並監測 aPTT 或 INR 與出血徵象。最危險的併發症是肺栓塞,表現為突發呼吸困難、胸痛、心跳加快與血氧下降。",[24,27,30,32],{"term":25,"count":26},"深部靜脈栓塞",6,{"term":28,"count":29},"霍曼氏徵象",4,{"term":31,"count":10},"艾倫試驗",{"term":33,"count":34},"動脈與靜脈循環障礙區辨",1,[36,40,45,49,54,59],{"webId":37,"stem":38,"number":39,"year":9,"session":10},"nurse-115-2-medical-surgical-021","有關癌細胞特性的敘述，下列何者正確？",21,{"webId":41,"stem":42,"number":43,"year":44,"session":34},"nurse-106-1-medical-surgical-067","有關甲狀腺風暴的臨床表徵，下列何者正確？",67,106,{"webId":46,"stem":47,"number":34,"year":48,"session":34},"nurse-107-1-medical-surgical-001","有關小腦病變之評估結果，下列何者錯誤？",107,{"webId":50,"stem":51,"number":52,"year":53,"session":34},"nurse-108-1-medical-surgical-039","有關癌症常見的腫瘤標記之敘述，下列何者錯誤？",39,108,{"webId":55,"stem":56,"number":57,"year":58,"session":10},"nurse-109-2-medical-surgical-003","有關慢性硬膜下出血（chronic subdural hematoma；chronic SDH）之敘述，下列何者正確？",3,109,{"webId":60,"stem":61,"number":62,"year":63,"session":10},"nurse-110-2-medical-surgical-037","病人接受化學治療後血小板數值為 10,000 cells\u002Fmm，下列何者為護理評估重點？",37,110,"2026-08-06",1787299037118]