病人發生癲癇發作，護理師應採取哪些措施？（選所有適合的）
A nurse is caring for a client who has a seizure. Which actions are appropriate for the nurse to take? (Select all that apply.)
- AInsert a tongue blade into the mouth將壓舌板插入口中
- BTurn the client to the side✓ 正解將病人轉為側臥
- CClear the area of hard objects✓ 正解清除周圍的硬物
- DRestrain the client's limbs to prevent injury約束病人四肢以防止受傷
- ETime the duration of the seizure✓ 正解記錄發作的持續時間
癲癇發作時，護理師的核心目標為保護病人免受物理傷害並維持呼吸道暢通。臨床處置應以安全（Safety）與觀察（Observation）為優先。正確行為包括移除周遭危險物以防碰撞、側臥以利口咽分泌物引流與預防舌頭後墜阻塞氣道、記錄發作持續時間以協助醫師評估發作類型與嚴重度。嚴禁強行張口或約束肢體，這些動作易導致牙齒斷裂、軟組織受傷或骨折。
During a seizure, the nurse's main goals are to protect the client from physical harm and to maintain a patent airway. Clinical management should prioritize safety and observation. Appropriate actions include removing nearby hazards to prevent impact, positioning the client on the side to facilitate oropharyngeal drainage and prevent airway obstruction from the tongue, and timing the duration of the seizure to assist the provider in assessing seizure type and severity. Forcing the mouth open or restraining the limbs is strictly contraindicated, as these actions can cause broken teeth, soft-tissue injury, or fractures.