— 基本照護與舒適 · MEDIUM · SATA —
護理師為有癲癇病史的病人規劃照護計畫，應優先採取哪些安全措施？（選所有適合的）
A nurse is planning care for a client with a history of seizures. Which interventions should the nurse prioritize to ensure patient safety? (Select all that apply.)
- AKeep padded side rails up at all times✓ 正解隨時保持襯墊床欄升起
- BMaintain a suction setup at the bedside✓ 正解在床邊準備抽吸設備
- CRestrict all physical activity限制所有身體活動
- DPlace a padded tongue blade at the bedside在床邊放置襯墊壓舌板
- EEnsure the bed is in the lowest position✓ 正解確保病床處於最低位置
— Explanation · 中文詳解 —
癲癇安全照護的核心是預防受傷與維持呼吸道通暢。床欄加墊、床位調低能預防跌傷；吸痰設備能處理發作後的口腔分泌物。約束活動（C）不符合醫療倫理；在現代護理實務中，口腔內塞入壓舌板（D）已證實會造成牙齒損傷或氣道阻塞，屬於禁止事項。
The core of seizure safety care is preventing injury and maintaining airway patency. Padded side rails and a lowered bed prevent fall injuries; suction equipment manages oral secretions after the seizure. Restraining movement (C) is not consistent with medical ethics; in modern nursing practice, inserting a tongue blade into the mouth (D) has been shown to cause tooth damage or airway obstruction and is prohibited.
✦ 台美臨床差異
美台護理皆已廢除『發作時塞入壓舌板』的傳統作法，此題正確反映了現代臨床的安全標準。