護理師照護一位有癲癇病史的病人,哪些環境調整對於安全是必要的?(選所有適合的)
A nurse is caring for a client with a history of seizures. Which environmental modifications are necessary for safety? (Select all that apply.)
- APadded side rails✓ 正解加墊床欄
- BSuction equipment at the bedside✓ 正解床邊備有抽吸設備
- COxygen setup ready for use✓ 正解準備好氧氣設備以供使用
- DRemoving all furniture from the room移除房間內的所有傢俱
- EPlacing a tongue blade at the bedside床邊放置壓舌板
癲癇發作(Seizure)的環境安全核心在於預防受傷與維持呼吸道通暢。病人在發作時會出現全身性抽搐,床欄加墊(Padded side rails)可防止撞擊造成骨折或挫傷;抽吸設備(Suction)與氧氣(Oxygen)則是應對發作後可能出現的呼吸道分泌物阻塞或缺氧的必要準備。臨床上,安全護理應考量「預防性環境準備」而非「過度干預」。
Environmental safety for seizures focuses on preventing injury and maintaining a patent airway. During a seizure, the client may have generalized convulsions; padded side rails prevent fractures or contusions from impact, while suction equipment and oxygen are necessary to manage postictal airway secretions or hypoxia. Clinically, safe nursing care should emphasize "preventive environmental preparation" rather than "excessive intervention."
在美國臨床實務中,對於癲癇病患的床欄加墊(Padded side rails)屬於常見的預防性安全措施,且嚴格禁止在發作中放置壓舌板(Tongue blade)是 NCLEX 的核心考點,這點與台灣目前的標準護理準則已趨於一致。