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照護管理 · MEDIUM · MCQ

護理師正在管理一位正在經歷癲癇發作的病人,應採取下列何項措施?

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

  • APlace a padded tongue blade in the client's mouth
    在病人口中放置包紮過的舌壓板
  • BRestrain the client's limbs to prevent injury
    約束病人四肢以預防受傷
  • CTurn the client onto their side✓ 正解
    將病人轉為側臥
  • DAdminister diazepam IV push immediately
    立即靜脈推注給藥地西泮
Explanation · 中文詳解

癲癇發作時,護理師應確保病人安全,重點在於維持呼吸道通暢與預防外傷。將病人側臥有助於口腔內分泌物或嘔吐物流出,防止其阻塞氣道而引發吸入性肺炎。約束肢體(B)會增加肌肉拉傷或骨折風險;放入壓舌板(A)會造成口腔損傷與氣道阻塞。給予靜脈藥物(D)需由醫師醫囑執行,且發作當下靜脈注射困難,非首要護理措施。

During a seizure, the nurse should ensure patient safety, with emphasis on maintaining airway patency and preventing injury. Positioning the patient on their side allows oral secretions or vomitus to drain out and prevents airway obstruction and aspiration pneumonia. Restraining the limbs (B) increases the risk of muscle strain or fractures; placing a padded tongue blade in the mouth (A) causes oral injury and airway obstruction. Administering IV medication (D) requires a physician's order and is difficult to perform during active seizure activity, so it is not the priority nursing action.

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