— 生理適應 · EASY · MCQ —
護理師正在評估一位癲癇發作的病人。何項為優先護理措施？
A nurse is assessing a client experiencing a seizure. Which is the priority nursing action?
- AEnsure a patent airway and protect the client from injury✓ 正解確保呼吸道通暢並保護病人免受傷害
- BPlace a padded tongue blade in the client's mouth在病人口中放置包覆軟墊的壓舌板
- CAdminister an antiepileptic medication給予抗癲癇藥物
- DRestrain the client's limbs約束病人四肢
— Explanation · 中文詳解 —
癲癇發作時的護理優先順序為維持呼吸道通暢與病人安全。根據 ABC（Airway, Breathing, Circulation）原則，護理師應先確保病人呼吸道不被分泌物或嘔吐物阻塞，並保護頭部與身體免受碰撞傷害。強行約束或強行放入口腔異物皆會造成額外傷害，抗癲癇藥物則待發作穩定後由醫師評估醫囑給予。
Nursing priorities during a seizure are maintaining a patent airway and ensuring the client's safety. Following the ABC (Airway, Breathing, Circulation) framework, the nurse must first ensure that the client's airway is not obstructed by secretions or vomitus, and protect the head and body from injury. Forcibly restraining the client or inserting objects into the mouth causes additional harm. Antiepileptic medications are given on the physician's order only after the seizure stabilizes.