— 降低風險 · EASY · MCQ —
護理師照護一位有癲癇病史的病人，為了減少強直陣攣發作時的受傷風險，應優先採取哪項措施？
A nurse is caring for a client with a history of seizures. Which intervention should the nurse prioritize to reduce the risk of injury during a tonic-clonic seizure?
- ATurn the client to the side✓ 正解將病人轉為側臥
- BLower the side rails of the bed降低病床護欄
- CInsert a padded tongue blade插入包裹軟墊的壓舌板
- DRestrain the client's arms and legs約束病人的手臂和腿部
— Explanation · 中文詳解 —
癲癇發作時的護理優先順序為「安全（Safety）」。強直陣攣發作（Tonic-clonic seizure）期間，最危險的併發症是呼吸道阻塞與誤吸（Aspiration）。將病人轉向側臥位（Side-lying position）能利用重力使口水分泌物或嘔吐物排出，確保呼吸道通暢，這是所有措施中最優先且關鍵的保護性動作。
The nursing priority during a seizure is safety. During a tonic-clonic seizure, the most dangerous complications are airway obstruction and aspiration. Turning the client to a side-lying position uses gravity to allow secretions or vomitus to drain from the mouth and maintain a patent airway. This is the most important and protective action of all available interventions.