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安全與感染控制 · MEDIUM · SATA

護理師照護一位有癲癇病史的病人,應採取哪些安全預防措施?(選所有適合的)

A nurse is caring for a client with a history of seizures. What safety precautions should be initiated? (Select all that apply.)

  • AKeep a padded tongue blade at the bedside
    在床邊放置有軟墊的舌壓板
  • BEnsure the bed is in the lowest position✓ 正解
    確保病床處於最低位置
  • CMaintain suction equipment at the bedside✓ 正解
    在床邊維持抽吸設備
  • DKeep side rails up at all times
    隨時升起床欄
  • EPlace a pillow under the client's head during a seizure✓ 正解
    在發作期間將枕頭置於病人頭下
Explanation · 中文詳解

癲癇病人的安全照護原則:B. 病床保持最低位以減少跌落傷害;C. 床邊備妥抽吸設備以清除發作時的口腔分泌物;E. 發作時於頭下墊枕緩衝撞擊。錯誤:A. 已棄用——強制置入舌壓板會導致牙齒折斷或氣道異物;D. 「全程升起所有床欄」在現行 NCLEX 標準中視為約束(restraint),且病人試圖跨越時可能跌落或卡傷;正確做法是使用「有軟墊的部分床欄」。

Safety care principles for clients with seizures: B. Keep the bed in its lowest position to reduce injury from falls; C. Keep suction equipment at the bedside to manage oral secretions during a seizure; E. Place a pillow under the head during a seizure to cushion against impact. Incorrect: A. Has been abandoned — forcibly inserting a tongue blade can cause dental fractures or airway foreign body; D. Keeping all side rails up at all times is considered a restraint under current NCLEX standards, and a client attempting to climb over the rails may fall from a greater height or become trapped; the correct practice is to use padded partial side rails.

✦ 台美臨床差異

美台對於癲癇病患的照護準則已趨於一致,均不再建議使用咬口器或壓舌板,重點皆轉向環境安全保護。

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