護理師為一位有癲癇病史的病人規劃護理計畫，應包含哪些降低受傷風險的措施？（選所有適合的）
A nurse is caring for a client with a history of seizures. Which actions should the nurse include in the care plan to reduce risk of injury? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將病床保持在最低位置
- BKeep side rails up while the client is in bed✓ 正解當客戶在床上時，拉起床欄
- CInsert a padded tongue blade during a seizure在癲癇發作期間插入包墊的壓舌板
- DEnsure oxygen and suction equipment are at the bedside✓ 正解確保氧氣和抽吸設備在床邊
- EMaintain a clear environment to prevent falls✓ 正解保持環境清空以防止跌倒
針對有癲癇病史的病人，護理計畫的目標是預防發作時的潛在傷害（Injury Prevention）。標準安全預防措施包括：維持低床位以防跌落、升起床欄保護病人不墜床、確保病室內有隨時可用的氧氣與抽吸設備（Suction）以應對發作後的呼吸道清理，並保持環境整潔以減少碰撞風險。這些措施均符合 NCLEX 對於安全照護的優先級要求。
For a client with a history of seizures, the nursing plan focuses on preventing injury during a seizure. Standard safety measures include keeping the bed in the lowest position to minimize fall injury, raising the side rails to protect against falling out of bed, ensuring that oxygen and suction equipment are readily available at the bedside to manage post-ictal airway clearance, and maintaining a clear environment to reduce the risk of collisions. These measures align with the NCLEX prioritization of safe care.