— 照護管理 · MEDIUM · SATA —
護理師照顧一位有癲癇病史的病人，應執行哪些癲癇防護措施？（選所有適合的）
A nurse is managing a client with a history of seizures. Which interventions should be implemented for seizure precautions? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將病床保持在最低位置
- BEnsure oxygen and suction equipment are at the bedside✓ 正解確保氧氣和抽吸設備在床邊可用
- CPlace the client on their back during a seizure在癲癇發作期間將病人置於仰臥姿勢
- DPad the side rails of the bed✓ 正解在病床護欄上鋪設軟墊
- ELoosen any clothing around the neck✓ 正解鬆開頸部周圍的任何衣物
— Explanation · 中文詳解 —
癲癇防護措施旨在預防病人受傷及維持呼吸道通暢。包括降低床位、備好氧氣與抽吸設備（預防呼吸道阻塞）、鋪設側欄軟墊，以及發作時鬆開頸部衣物。正確的擺位應為側臥（Recovery position）以防吸入性肺炎，而非仰臥。
Seizure precautions are intended to prevent injury and maintain a patent airway. They include keeping the bed in the lowest position, having oxygen and suction equipment ready (to prevent airway obstruction), padding the side rails, and loosening clothing around the neck during a seizure. Correct positioning is side-lying (recovery position) to prevent aspiration pneumonia rather than supine.
✦ 台美臨床差異
美台癲癇照護標準一致，但台灣病房側欄軟墊的使用普及率在部分醫院仍需透過特別醫囑請求。