護理師照護一位有癲癇病史的病人，哪項評估結果應被優先視為癲癇發作期間潛在呼吸道風險的指標？
A nurse is caring for a client with a history of seizures. Which assessment finding should the nurse prioritize as an indicator of potential airway risk during a seizure?
- AOccasional twitching of the small facial muscles面部小肌肉偶爾抽搐
- BExcessive oral secretions noted during the postictal phase✓ 正解發作後期注意到口腔分泌物過多
- CPresence of a strong gag reflex prior to the seizure發作前存在強烈的咽反射
- DBilateral pupillary dilation during the tonic phase強直期雙側瞳孔散大
核心概念：癲癇安全管理與呼吸道保護。癲癇發作中最致命的風險之一是吸入性肺炎或呼吸道阻塞。為何正確答案對：發作後（postictal phase）病人意識尚未完全恢復，且常伴隨大量口腔分泌物（B），這會導致窒息或誤吸。為何其他選項錯：A 是正常生理保護，A 是癲癇的常見表現但非呼吸道風險，D 屬於自主神經反應。臨床思路：遵循 ABC 優先原則，呼吸道（Airway）永遠是首要評估點。在癲癇護理中，側臥位（side-lying position）的目的是讓分泌物流出，這直接針對的就是選項 B 的風險。
Core concept: seizure safety and airway protection. One of the most lethal complications during seizures is aspiration pneumonia or airway obstruction. The correct answer: in the postictal phase consciousness has not fully returned and excessive oral secretions (B) can cause choking or aspiration. The other options: C is a normal protective reflex, A is a typical seizure manifestation but not an airway risk, and D is an autonomic response. The clinical priority follows ABC; airway (C) is always first. Side-lying positioning during seizure care lets secretions drain and directly addresses the risk in option B.
美國強調癲癇發作時「嚴禁放入任何物品」到口中，並極度重視發作後的擺位與氧氣準備；台灣早期民間觀念偶有「塞毛巾防止咬舌」，護理師需在衛教中強力糾正此類危險行為。