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安全與感染控制 · MEDIUM · MCQ

病人發生癲癇發作,護理師應採取哪項措施?

A client is experiencing a seizure. Which action should the nurse take?

  • ARestrain the client's extremities
    約束病人的四肢
  • BTry to open the jaw to prevent biting
    試圖張開下顎以防止咬傷
  • CTurn the client to the side✓ 正解
    將病人轉為側臥
  • DPlace a padded tongue blade in the mouth
    在口中放入墊有布條的壓舌板
Explanation · 中文詳解

癲癇發作(Seizure)時,護理師的護理核心是「維持呼吸道暢通」與「防止身體受傷」。將病人轉為側臥(Side-lying position)能防止舌頭後墜堵塞氣道,並確保口腔內的分泌物或嘔吐物能順利流出,避免引發吸入性肺炎。同時,應移除周圍尖銳物品。嚴禁將任何物體強行塞入口中(包括壓舌板),因為這會導致病人牙齒斷裂或阻塞氣道,增加窒息風險。

During a seizure, the nurse's priorities are to maintain a patent airway and prevent injury. Turning the client into a side-lying position prevents posterior displacement of the tongue from occluding the airway and allows oral secretions or vomitus to drain, reducing the risk of aspiration pneumonia. Sharp objects should also be removed from the surroundings. Forcing any object into the mouth (including a tongue blade) is strictly contraindicated, because it can fracture teeth or obstruct the airway and increase the risk of asphyxia.

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