護理師照護一名有癲癇病史的病人，下列哪些護理措施能確保其安全？（選所有適合的）
A nurse is caring for a client with a history of seizures. Which interventions should the nurse include in the plan of care to ensure safety? (Select all that apply.)
- AKeep a suction setup at the bedside✓ 正解在床邊準備抽吸裝置
- BPad the side rails of the bed✓ 正解為床欄加裝軟墊
- CMaintain the client on their back during a seizure使病人在發作期間保持仰臥姿勢
- DLoosen any clothing around the neck✓ 正解鬆開頸部周圍的任何衣物
- EInsert a padded tongue blade during active seizure在發作期間插入加墊的壓舌板
癲癇（Seizure）發作時的護理首重「安全」與「氣道保護」。護理師應移除周圍危險物品，保護頭部，並在發作後側臥（Recovery position）以利口水流出，預防吸入性肺炎。正確選項 A、B、D 分別對應了呼吸道準備、防撞傷與維持呼吸通暢的需求。錯誤選項 C 容易導致舌頭後墜阻塞呼吸道；E 選項則違反現代護理準則，強制塞入物體極易造成牙齒斷裂或口腔組織撕裂傷。
Nursing care during a seizure focuses primarily on safety and airway protection. The nurse should remove hazardous objects from the surrounding area, protect the head, and after the seizure place the client in a side-lying recovery position to allow saliva to drain and prevent aspiration pneumonia. Correct options A, B, and D address airway preparation, prevention of impact injury, and maintenance of airway patency, respectively. Incorrect option C is wrong because supine positioning can allow the tongue to fall back and obstruct the airway. Option E violates current nursing guidelines; forcibly inserting an object into the mouth can fracture teeth or lacerate oral tissues.
美國臨床對於癲癇發作的「禁忌」教育非常嚴格，特別是強調絕對不可強行塞入任何物體（No tongue blades），這點與台灣臨床現況一致，但在 NCLEX 考試中，此點是絕對不能選的陷阱。