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安全與感染控制 · MEDIUM · MCQ

護理師為癲癇高風險病人執行癲癇預防措施時,哪項介入最優先?

Which of the following interventions is a priority for a nurse implementing seizure precautions for a client at high risk of injury?

  • APadding the side rails of the bed✓ 正解
    為床邊護欄加裝軟墊
  • BRestraining the client's extremities
    約束病人的四肢
  • CPlacing a tongue blade at the bedside
    在床邊放置壓舌板
  • DMaintaining a continuous bedside light
    維持床邊持續照明
Explanation · 中文詳解

癲癇發作(Seizure)的護理重點在於保護病人安全,預防外傷。加裝床欄並包覆軟墊,可防止病人在肢體強直或陣攣抽動時,撞擊堅硬床欄而導致外傷、骨折或頭部創傷。這是環境安全防護的第一優先,且是預防性措施。其他選項如放置壓舌板已被現代實證護理排除,因為這不僅無法防止咬舌,反而可能造成牙齒損壞或氣道阻塞。

The focus of nursing care during a seizure is protecting the client's safety and preventing trauma. Raising the side rails and padding them prevents the client from striking hard rails and sustaining trauma, fractures, or head injury during tonic or clonic movements. This is the first priority of environmental safety protection and is a preventive measure. Other options such as placing a tongue depressor have been excluded by current evidence-based practice because doing so does not prevent tongue biting and may cause dental injury or airway obstruction.

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