— 生理適應 · EASY · MCQ —
護理師在照顧癲癇發作的病人時，應優先採取哪項行動？
Which action should the nurse prioritize when caring for a client experiencing a seizure?
- ARestrain the client's extremities約束個案的四肢
- BAttempt to open the client's jaw嘗試撬開個案的下顎
- CInsert a padded tongue blade插入包覆軟墊的壓舌板
- DProtect the client's head from injury✓ 正解保護個案的頭部免受傷害
— Explanation · 中文詳解 —
癲癇發作時的護理首重安全與呼吸道維持。保護頭部避免碰撞是防止外傷的核心步驟。現在的標準護理常規已不建議強行約束肢體，也不建議放置舌壓板或強制撬開嘴巴，因為這些舉動反而容易導致骨折或牙齒斷裂掉入呼吸道。
During a seizure, nursing care focuses on safety and maintaining the airway. Protecting the head from injury is the core step in preventing trauma. Current standards of care no longer recommend forcibly restraining the limbs, inserting a padded tongue blade, or prying open the jaw, because such actions are more likely to cause fractures or broken teeth that can fall into the airway.
✦ 台美臨床差異
台美臨床指引皆已廢除放置舌壓板，但美國在床邊安全設備的規範（如 Side rail padding）更為普及。