一位病人發生強直陣攣性癲癇發作，護理師應優先採取哪項措施？
A nurse is caring for a patient experiencing a tonic-clonic seizure. Which action should the nurse take first?
- ARestrain the client's limbs to prevent injury限制病人的四肢以防止受傷
- BInsert a bite block to prevent tongue biting插入咬口以防止咬傷舌頭
- CProtect the client's head from injury✓ 正解保護病人的頭部免受傷害
- DAdminister intravenous lorazepam給予靜脈注射勞拉西泮
面對強直陣攣性癲癇（Tonic-clonic seizure），護理師的首要任務是「確保病人安全」，避免病人因劇烈抽搐而導致外傷。ABC（呼吸道、呼吸、循環）固然重要，但在發作當下，預防頭部撞擊是優先級最高的物理保護措施。護理師應移除周圍危險物品，並在頭下墊柔軟物。切記，絕不可強行限制肢體活動或放入異物，以免造成骨折、咬傷或牙齒斷裂。
When facing a tonic-clonic seizure, the nurse's first priority is to 'ensure the client's safety' and prevent traumatic injury from violent convulsions. ABCs (airway, breathing, circulation) are certainly important, but during the seizure itself, preventing head impact is the highest-priority physical protective measure. The nurse should remove hazardous objects from the surroundings and place something soft under the head. Never physically restrain the limbs or place objects in the mouth, as this can cause fractures, lacerations, or tooth fractures.