一位病人正在經歷強直陣攣性癲癇發作。護理師應採取何種措施以確保其安全？
A client is experiencing a tonic-clonic seizure. Which action should the nurse take to ensure client safety?
- AForce the client to drink water to prevent dehydration強迫病人喝水以預防脫水
- BAttempt to restrain the client's limbs嘗試約束病人的四肢
- CTurn the client to their side and loosen tight clothing✓ 正解將病人轉為側臥並鬆開緊身衣物
- DPlace a padded tongue blade in the client's mouth在病人口中放入包覆軟墊的壓舌板
癲癇發作（Seizure）時的護理核心在於維護病人安全並防止二次傷害。強直陣攣性癲癇（Tonic-clonic seizure）會導致全身肌肉僵硬與抽搐，此時護理師應保持冷靜，移開周圍危險物品，維持呼吸道通暢，並協助病人採側臥姿（Side-lying position）以預防舌根後墜或嘔吐物吸入。切勿強行約束病人或將任何異物塞入病人口中，這些舉動極易造成骨折、軟組織撕裂傷或牙齒斷裂。
The core of nursing care during a seizure is to maintain client safety and prevent secondary injury. A tonic-clonic seizure causes generalized muscle rigidity and convulsions; the nurse should remain calm, remove hazardous objects from the surrounding area, keep the airway patent, and assist the client into a side-lying position to prevent the tongue from falling back or aspiration of vomitus. The nurse must never forcibly restrain the client or insert any object into the client's mouth, as these actions can easily cause fractures, soft tissue tears, or broken teeth.
美國臨床護理實務中，對於癲癇病人的護理原則已非常明確：『不要在病人口中放置任何東西』。在台灣臨床環境中，部分資深人員仍有放置壓舌板的習慣，但這已不符合實證護理標準（Evidence-based practice），在 NCLEX 考試中務必選擇『保持呼吸道暢通、側臥、不約束』的選項。