對於有癲癇病史的病人，在強直陣攣性發作期間應採取哪些措施？（選所有適合的）
A nurse is caring for a client with a history of seizures. Which interventions are indicated during a tonic-clonic seizure? (Select all that apply.)
- ATurn the client to the side✓ 正解將個案轉為側臥
- BInsert a bite block插入咬口器
- CTime the seizure duration✓ 正解記錄發作持續時間
- DClear the area of hazards✓ 正解清除周遭危險物品
- ERestrain the limbs約束肢體
癲癇強直陣攣性發作（Tonic-clonic seizure）的護理核心在於「保護病人免受二次傷害」並「維持呼吸道通暢」。護理師應保持冷靜，側臥姿勢（Recovery position）能防止舌頭後墜或口水、嘔吐物導致的吸入性肺炎。移除周邊危險物品是為了防止抽搐時肢體猛烈撞擊硬物。此外，精確紀錄發作時間與型態是評估癲癇控制狀況及醫師調整抗癲癇藥物（Antiepileptic drugs）的重要依據。
The core of nursing care for a tonic-clonic seizure is protecting the client from secondary injury and maintaining airway patency. The nurse should remain calm; the recovery (side-lying) position prevents the tongue from falling back and prevents aspiration pneumonia from saliva or vomit. Removing hazardous objects from the surroundings prevents limbs from striking hard objects during convulsions. In addition, precise documentation of seizure duration and pattern is an important basis for evaluating seizure control and adjusting antiepileptic drugs.