— 降低風險 · MEDIUM · MCQ —
護理師照護一位有癲癇病史的病人。在強直陣攣性發作時，哪項護理行動是優先事項？
A nurse is caring for a client with a history of seizures. Which nursing action is priority during a tonic-clonic seizure?
- AInsert a bite block or tongue blade into the mouth將咬塊或舌壓板放入口中
- BProtect the client's head from injury✓ 正解保護病人头部免受傷害
- CAttempt to stop the seizure with medication嘗試用藥物停止發作
- DRestrain the client's limbs to prevent injury約束病人的四肢以防止受傷
— Explanation · 中文詳解 —
癲癇發作時的優先原則是保護病人安全。保護頭部避免撞擊地面或床欄是首要行動。絕對不可強行置入咬合板，以免造成牙齒斷裂或吸入異物。約束肢體會導致肌肉或骨骼受傷。立即給予藥物通常在發作時間過長時才執行，非當下第一步。
The priority during a seizure is to protect the client from injury. Protecting the head from striking the floor or bed rails is the first action. Force-inserting a bite block is strictly prohibited because it can fracture teeth or be aspirated. Restraining the limbs can cause muscle or skeletal injury. Administering medication is generally reserved for prolonged seizures (status epilepticus) and is not the first step during an active seizure.
✦ 台美臨床差異
臨床實務中，台灣醫院常由照護者優先移除病床護欄或淨空環境，美國則更強調側臥姿勢（Recovery position）以保持呼吸道暢通。