一位病人出現強直陣攣性發作，護理師的優先護理處置為何？
A client is experiencing a tonic-clonic seizure. Which of the following is the priority nursing intervention?
- ARestrain the client's extremities to prevent thrashing約束病人四肢以防止掙扎
- BAttempt to give oral anti-seizure medication嘗試給予口服抗癲癇藥物
- CProtect the client from injury by clearing the area✓ 正解清理周圍區域以保護病人免受傷害
- DInsert a padded tongue blade into the mouth將包紮過的壓舌板插入口中
強直陣攣性發作（Tonic-clonic seizure）的護理核心在於「安全防護」與「避免二次傷害」。發作時病人肌肉強直及陣攣可能導致碰撞受傷，優先處置應是移除周遭危險物品，而非進行侵入性干預。發作過程中強行干預（如塞入異物或約束）極易導致病人牙齒斷裂、軟組織損傷或骨折，甚至因刺激加劇抽搐。護理師應保持冷靜，記錄發作時間與特徵，待抽搐停止後再評估呼吸道與生命徵象。
The core of nursing care during a tonic-clonic seizure is to ensure safety and prevent secondary injury. Because the client's muscles are tonic and clonic and may collide with surrounding objects, the priority is to remove hazards from the environment rather than to perform invasive interventions. Forcible intervention during the seizure (such as inserting an object or restraining the client) can easily fracture teeth, injure soft tissues, or cause fractures, and stimulation may even worsen the convulsions. The nurse should remain calm, document the time and characteristics of the seizure, and reassess the airway and vital signs after convulsions have stopped.