護理師督導一名照顧癲癇病史病人的輔助人員(AP)。下列哪項 AP 的行為需要護理師立即介入?
A nurse is supervising an assistive personnel (AP) who is providing care to a client with a history of seizures. Which action by the AP requires immediate intervention by the nurse?
- ATurning the client to the side during the seizure在癲癇發作期間將病人轉向側臥
- BClearing the area around the client to prevent injury清理病人周圍區域以防止受傷
- CPlacing a padded tongue blade into the client's mouth during a seizure✓ 正解在癲癇發作期間將包覆軟墊的壓舌板放入病人口中
- DLoosening the clothing around the client's neck鬆開病人頸部周圍的衣物
護理師需確保輔助人員(AP)的操作符合病人安全規範。針對癲癇病史的病人,癲癇發作時的錯誤護理(如強塞壓舌板)會造成嚴重傷害。一旦發現 AP 採取此類危險動作,護理師必須立即介入制止,並教育正確的發作護理知識,包括保護頭部、側臥(Recovery position)及清理環境,以保障病人呼吸道通暢與身體安全。
The nurse must ensure that assistive personnel (AP) practice within patient-safety standards. For a client with a history of seizures, incorrect seizure care (such as forcing a tongue blade into the mouth) can cause serious harm. Once such a dangerous action by the AP is observed, the nurse must immediately intervene to stop it and teach correct seizure management, including protecting the head, placing the client in a side-lying (recovery) position, and clearing the surroundings, in order to maintain a patent airway and prevent injury.