— 生理適應 · EASY · SATA —
護理師照護有癲癇病史的病人時，應執行哪些措施？（選所有適合的）
Which actions should the nurse perform when providing care for a client with a history of seizures? (Select all that apply.)
- AMaintain side rails in the up position✓ 正解保持床欄處於升起位置
- BKeep a padded tongue blade at the bedside在床邊準備壓舌板
- CEnsure suction equipment is available✓ 正解確保抽吸設備可用
- DLoosen restrictive clothing around the neck✓ 正解鬆開頸部周圍緊縮的衣物
- EPlace the client on their back during a seizure在癲癇發作期間讓病人仰臥
— Explanation · 中文詳解 —
癲癇發作防護重點：安全環境（床欄上鎖）、呼吸道通暢（抽吸設備）。發生時應解開緊身衣物、避免頭部受傷。不可強行放置舌壓板（易致牙齒損壞或異物吸入），且應採取側臥位（Recovery position）以防誤吸，而非仰臥。
Key protective measures for seizures include a safe environment (side rails up and locked) and a patent airway (suction equipment available). When a seizure occurs, restrictive clothing should be loosened and head injury prevented. Inserting a tongue blade is contraindicated (it can damage teeth or be aspirated), and the client should be placed in the side-lying (recovery) position rather than supine to prevent aspiration.
✦ 台美臨床差異
美台皆已摒棄在發作時使用壓舌板的過時做法，臨床重點皆聚焦於保護病人頭部與呼吸道照護。