一位病患正在經歷強直陣攣性癲癇發作，下列哪些護理措施是適當的？（選所有適合的）
A nurse is caring for a patient experiencing a tonic-clonic seizure. Which nursing interventions are appropriate? (Select all that apply.)
- ATurn the client to their side to prevent aspiration✓ 正解將病人轉為側臥以預防吸入
- BPlace a padded tongue blade in the client's mouth在病人口中放置加墊的壓舌板
- CClear the area around the client to prevent injury✓ 正解清除病人周圍區域以防止受傷
- DLoosen any restrictive clothing around the neck✓ 正解鬆開頸部周圍任何限制性衣物
- EAttempt to restrain the client's extremities to stop shaking嘗試約束病人的四肢以停止抽搐
強直陣攣性癲癇發作（Tonic-clonic seizure）的護理核心在於維護呼吸道通暢（ABC原則）與預防外傷。發作時，病患失去意識且肌肉強直與陣攣，護理師應維持側臥姿勢以防吸入性肺炎，移除周遭危險物以避免撞傷，並適度鬆開頸部束縛以利呼吸。強制約束或放置任何物品於口中均會增加骨折或口腔損傷風險。
The core of nursing care for a tonic-clonic seizure is maintaining a patent airway (ABC principle) and preventing injury. During a seizure, the client loses consciousness and exhibits tonic and clonic muscle activity; the nurse should maintain a side-lying position to prevent aspiration pneumonia, remove surrounding hazards to avoid injury, and gently loosen neck restrictions to facilitate breathing. Restraining the client forcibly or placing any object in the mouth increases the risk of fractures or oral injury.
美國臨床護理實務嚴格禁止在癲癇發作時往口中放置任何異物。台灣部分舊式觀念或非專業人士仍有放壓舌板的習慣，但這在 NCLEX 中是絕對錯誤的選項。