護理師照顧一位有癲癇病史的病人，下列哪些癲癇預防措施是適當的？（選所有適合的）
A nurse is caring for a client with a history of seizures. Which nursing interventions are appropriate for seizure precautions? (Select all that apply.)
- AKeep the side rails up and padded✓ 正解保持床欄升起並加襯墊
- BMaintain suction equipment at the bedside✓ 正解在床旁備妥抽吸設備
- CInsert a padded tongue blade if the client begins to seize若病人開始抽搐，插入襯墊壓舌板
- DEnsure O2 equipment is set up and functional✓ 正解確保氧氣設備已設置且功能正常
- ELoosen any restrictive clothing around the neck✓ 正解鬆開頸部周圍任何限制性衣物
癲癇預防措施（Seizure precautions）的核心目的在於防止病人於發作期間受傷，並確保呼吸道暢通。護理重點包括環境安全配置與緊急設備準備。強直陣攣性發作（Tonic-clonic seizure）時，病人可能因意識喪失與全身肌肉痙攣而發生跌倒、咬傷舌頭或呼吸道阻塞。護理師應採取預防跌倒措施（如床欄加墊），並確保床邊備有急救設備（抽吸與氧氣），以便發作後立即清理呼吸道與維持氧合。禁止於發作中強行放入異物，以免造成牙齒斷裂或氣道阻塞。
The purpose of seizure precautions is to prevent injury during a seizure and to maintain a patent airway. Key nursing measures include arranging a safe environment and preparing emergency equipment. During a tonic-clonic seizure, the client may fall, bite the tongue, or develop airway obstruction due to loss of consciousness and generalized muscle contractions. The nurse should institute fall-prevention measures (such as padded side rails) and keep suction and oxygen at the bedside so that the airway can be cleared and oxygenation maintained after the seizure. Inserting objects forcibly during a seizure is prohibited because it can fracture teeth or obstruct the airway.
在美國臨床執業中，Seizure precautions 幾乎是所有高風險病人的常規醫囑（Standard orders），護理師需在交班時確認設備完好，這與台灣臨床對此項目的執行嚴謹度高度一致。