護理師照護一位有癲癇病史的病人,哪些護理措施優先?(選所有適合的)
A nurse is caring for a client with a history of seizures. What interventions are priority? (Select all that apply.)
- AKeep suction equipment at the bedside✓ 正解在床邊備妥抽吸設備
- BPlace an oxygen mask on the client during the seizure在病人發作期間戴上氧氣面罩
- CRemove harmful objects from the immediate area✓ 正解移除周圍的危險物品
- DRecord the time and duration of the seizure✓ 正解記錄發作的時間與持續時間
- EProvide soft restraints to the wrists為手腕提供軟式約束帶
癲癇發作時的護理優先順序為「保護安全」與「維持呼吸」。備妥抽吸設備(Suction)是為了在發作後清理口腔分泌物,避免呼吸道阻塞;移除危險物品是為了防止受傷;詳細記錄發作過程(時間、動作、意識狀態)則是醫師調整藥物的重要參考。不可使用拘束器(Restraints),因為發作時強烈的肌肉收縮若遇拘束,極易導致骨折。
During a seizure, nursing priorities are 'safety protection' and 'maintaining breathing.' Keeping suction equipment ready is important for clearing oral secretions after the seizure and preventing airway obstruction; removing hazardous objects prevents injury; and detailed documentation of the seizure (time, motor activity, level of consciousness) provides important information for the physician adjusting medication. Restraints should not be used because the strong muscle contractions during a seizure, when met with restraint, can easily cause fractures.