一位有癲癇病史的病患，發生強直陣攣性發作時，護理師首要介入為何？
A nurse is providing care to a client with a history of seizure disorder. What is the priority nursing intervention during a tonic-clonic seizure?
- AInsert a bite block插入咬口器
- BAdminister an anticonvulsant medication給予抗癲癇藥物
- CRestrain the client's limbs約束病人的四肢
- DProtect the client's head from injury✓ 正解保護病人頭部免受傷害
在強直陣攣性發作（Tonic-clonic seizure）期間，護理師的首要任務是確保病人的安全，防止其因劇烈抽搐而導致外傷。保護頭部避免撞擊硬物是第一優先行動。約束肢體（Restraint）會因骨骼肌肉受到過大拉力而導致骨折，因此絕對禁止。咬口器（Bite block）已被現代護理指引移除，因其可能導致牙齒脫落並阻塞呼吸道。護理師應在發作期間側臥病人以保持呼吸道通暢，並觀察發作過程。
During a tonic-clonic seizure, the nurse's first priority is to ensure the client's safety by preventing injury from violent convulsions. Protecting the head from striking hard objects is the foremost action. Restraining the limbs is absolutely forbidden, as excessive pulling on the musculoskeletal system can cause fractures. Bite blocks have been removed from contemporary nursing guidelines, as they can cause dental injury and obstruct the airway. The nurse should position the client on their side during the seizure to maintain airway patency and observe the seizure event.