護理師照護一位有癲癇病史的病人。在強直陣攣性癲癇發作時，哪項介入最優先？
A nurse is caring for a client with a history of seizures. Which intervention is the highest priority during a tonic-clonic seizure?
- AAdminister an IV sedative給予靜脈注射鎮定劑
- BRestrain the client's extremities約束病人的四肢
- CInsert a bite block into the mouth將咬塊置入口中
- DProtect the client's head from injury✓ 正解保護病人头部免受傷害
癲癇發作期間的首要任務是病人安全，保護頭部避免撞擊是護理師最即時可執行的動作。不可強行插入異物（會導致牙齒損傷或阻塞氣道），不可綑綁肢體（會導致骨折），鎮靜劑需由醫師給予且需在發作持續時才執行。保持呼吸道暢通需待抽搐停止後再評估。
The top priority during a seizure is the client's safety; protecting the head from impact is the most immediate intervention the nurse can perform. Forcing objects into the mouth is prohibited (causes dental damage or airway obstruction); restraining the extremities must not be performed (causes fractures); and sedatives must be ordered by a physician and only given if the seizure is prolonged. Airway patency should be reassessed after the convulsion stops.
台美護理教案皆強調保護頭部，美國針對病人自尊與自主權更強調不要過度約束，台灣在預防跌倒方面會更強調加強床欄保護。