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照護管理 · EASY · SATA

護理師照護癲癇病史病人,應實施哪些安全措施?(選所有適合的)

A nurse is caring for a client with a history of seizures. Which interventions should the nurse implement to ensure safety? (Select all that apply.)

  • AKeep padded side rails up✓ 正解
    保持加墊床欄升起
  • BPlace an oral airway at the bedside
    在床邊放置口咽通氣道
  • CKeep suction equipment ready✓ 正解
    準備抽吸設備
  • DRestrain the client during a seizure
    在癲癇發作期間約束病人
  • ELoosen clothing around the neck✓ 正解
    鬆開頸部周圍的衣物
Explanation · 中文詳解

癲癇發作安全措施:床欄加墊預防撞傷(A)、備妥抽吸設備預防吸入性肺炎(C)、鬆開頸部衣物促進呼吸(E)。B 選項不建議,發作時強制塞入口腔異物易造成牙齒斷裂或阻塞呼吸道;D 選項錯誤,絕對禁止束縛病人,以免造成骨折或肌肉拉傷。

Seizure safety measures: padded side rails to prevent impact injuries (A), suction equipment ready to prevent aspiration pneumonia (C), and loosening clothing around the neck to facilitate breathing (E). Option B is not recommended; inserting objects into the mouth during a seizure can cause dental fractures or airway obstruction. Option D is incorrect; restraint of the client is absolutely contraindicated, as it can cause fractures or muscle strains.

✦ 台美臨床差異

美台皆強調不強塞異物,但美國教育更強調「側臥」姿勢(Recovery position)之推廣。

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