— 安全與感染控制 · EASY · MCQ —
護理師照護一位有癲癇病史的病人，下列哪項安全防護措施最為適切？
A nurse is caring for a client with a history of seizures. What is the most appropriate safety precaution to implement?
- APlacing a tongue blade in the client's mouth at all times隨時在病人口中放置壓舌板
- BMaintaining the client in a supine position使病人保持仰臥姿勢
- CRestraining the client's arms and legs約束病人的四肢
- DKeeping the side rails up and padded✓ 正解保持床欄拉起並加襯墊
— Explanation · 中文詳解 —
癲癇發作時的照護核心是預防外傷。將床欄升起並加裝軟墊，可防止病人在痙攣時撞傷。現代護理指引明確禁止放置壓舌板（會導致牙齒破損或呼吸道阻塞）或束縛病人，保持側臥位（復甦姿勢）才是有利於呼吸道通暢的正確姿勢。
The core of care during a seizure is prevention of injury. Raising the side rails and padding them prevents the patient from striking them during convulsions. Current nursing guidelines explicitly prohibit placing a tongue blade (which can cause dental damage or airway obstruction) or restraining the patient; placing the patient in the side-lying (recovery) position is the correct position for maintaining a patent airway.
✦ 台美臨床差異
台美臨床指引皆已完全揚棄「塞入壓舌板」這種舊式做法。