— 降低風險 · MEDIUM · SATA —
護理師照護一位正處於癲癇發作的病人，下列哪些行動是正確的？（選所有適合的）
A nurse is caring for a client who is having a seizure. Which actions should the nurse take? (Select all that apply.)
- ATurn the client to the side✓ 正解將病人轉向側臥
- BInsert a padded tongue blade into the mouth將包覆軟墊的舌片插入口中
- CLoosen restrictive clothing around the neck✓ 正解鬆開頸部周圍緊縮的衣物
- DProtect the client's head from injury✓ 正解保護病人头部免受傷害
- ERestrain the client's limbs to prevent injury約束病人四肢以防止受傷
— Explanation · 中文詳解 —
癲癇發作時，首要重點為安全防護：側臥以維持呼吸道通暢（避免嗆入分泌物）、鬆開領口衣物以利呼吸、保護頭部防止外傷。嚴禁強行張開口部放入物體（導致牙齒斷裂或吸入異物），且不可約束四肢，以免造成骨折或肌肉拉傷。
During a seizure, the priority is safety: place the client on their side to maintain a patent airway (preventing aspiration of secretions), loosen clothing around the neck to facilitate breathing, and protect the head from injury. It is strictly contraindicated to force the mouth open to insert objects (which may cause broken teeth or foreign-body aspiration), and the limbs must not be restrained, as this may cause fractures or muscle injuries.
✦ 台美臨床差異
美國護理指引明確強調不可放異物，台灣臨床部分資深人員仍有放置壓舌板的錯誤習慣，需持續進行實證護理教學。