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降低風險 · EASY · SATA

護理師照護一位有癲癇病史的病人,下列哪些護理措施應納入照護計畫?(選所有適合的)

A nurse is caring for a client with a history of seizures. Which interventions should the nurse include in the plan of care? (Select all that apply.)

  • AKeep a suction setup at the bedside✓ 正解
    在床邊備妥抽吸設備
  • BPlace padded side rails on the bed✓ 正解
    在床邊安裝軟墊護欄
  • CKeep a tongue blade at the bedside for emergency use
    在床邊備妥壓舌板以供緊急使用
  • DEnsure the client has an IV access✓ 正解
    確保客戶已建立靜脈通路
  • EMaintain the bed in the lowest position✓ 正解
    保持病床處於最低位置
Explanation · 中文詳解

癲癇(seizure)病人的照護核心在於「安全」與「預防受傷」。照護計畫應包含環境安全(如低床位、床欄軟墊)以及緊急應變準備(如抽吸設備、靜脈路徑建立)。現代護理指引明確指出,發作時不可強制將物品塞入病人口中(如舌壓板),以免造成牙齒折斷、口腔軟組織受損或阻塞呼吸道。靜脈路徑則是為了在癲癇持續狀態(status epilepticus)發生時,能立即給予抗癲癇藥物。

Care for a client with a seizure history centers on safety and prevention of injury. The plan should include environmental safety (low bed, padded side rails) and emergency readiness (suction setup, IV access). Current guidelines explicitly prohibit placing a tongue blade or any object in the client's mouth during a seizure because of risks of dental injury, oral trauma, and airway obstruction. IV access enables rapid administration of anticonvulsants if status epilepticus occurs.

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