護理師照顧一位有癲癇病史的病人。為了降低癲癇發作時的受傷風險，護理計畫應包含哪些措施？（選所有適合的）
A nurse is caring for a client with a history of seizures. Which actions should the nurse include in the client's care plan to reduce the risk of injury during a seizure? (Select all that apply.)
- AKeep a padded tongue blade at the bedside在床邊備妥包紮過的壓舌板
- BMaintain side rails in the up and padded position✓ 正解保持床欄拉起並加裝軟墊
- CRemove harmful objects from the immediate area✓ 正解清除周圍區域的危險物品
- DLoosen any restrictive clothing around the neck✓ 正解鬆開頸部周圍的任何限制性衣物
- EAttempt to restrain the client to prevent thrashing嘗試約束病人以防止掙扎
癲癇發作時的護理重點在於保護病人安全。嚴禁在口中放置壓舌板（會導致牙齒斷裂或氣道阻塞），也不可限制病人的動作，以免造成骨折或組織損傷。應採取環境防護，移除危險物品，維持床欄保護，並解開緊身衣物以維持呼吸道通暢。
The nursing focus during a seizure is to protect the client's safety. Inserting a padded tongue blade into the mouth is strictly prohibited (it may cause dental fractures or airway obstruction), and restraining the client is forbidden, as it can cause fractures or tissue injury. Environmental protective measures should be taken, including removing dangerous objects, maintaining padded side rails, and loosening restrictive clothing to keep the airway patent.
台美護理標準均已禁止放置壓舌板，但在台灣部分長照機構仍有錯誤觀念，需加強衛教。