護理師照護一位正發生強直陣攣癲癇的病人，優先採取哪項措施？
A nurse is caring for a client who is having a tonic-clonic seizure. What is the priority nursing action?
- ATurn the client to the side✓ 正解將病人轉為側臥
- BInsert a padded tongue blade插入包紮過的壓舌板
- CRestrain the client's extremities約束病人的四肢
- DCall the physician immediately立即通知醫師
強直陣攣癲癇（Tonic-clonic seizure）發作時，護理師的優先處置（Priority action）必須基於 ABC 原則（Airway, Breathing, Circulation）。病人發作時常伴隨分泌物增加及舌頭後墜，極易導致呼吸道阻塞。因此，維持呼吸道通暢是首要任務。側臥（Side-lying）能促進分泌物引流，防止誤吸（Aspiration），是臨床最安全且有效的優先動作。
During a tonic-clonic seizure, the nurse's priority action is based on the ABC principle (Airway, Breathing, Circulation). Increased secretions and posterior tongue displacement during the seizure can easily obstruct the airway. Maintaining airway patency is therefore the foremost task. A side-lying position promotes drainage of secretions and prevents aspiration, making it the safest and most effective priority intervention in clinical practice.
美國臨床護理實務對於癲癇發作的「禁止事項」非常嚴格，護理執照考試（NCLEX）極度強調絕對不可放入任何物品於病人口中，此觀念與台灣臨床偶見的老式做法不同，需特別留意。