一位有癲癇病史的病患正在發作,哪項措施最能確保病人安全?
A nurse is assisting a client with a history of seizures. Which intervention best promotes client safety during a seizure?
- ARestrain the extremities to prevent injury約束四肢以預防受傷
- BInsert a padded tongue blade into the mouth將包墊的舌壓板插入口中
- CAttempt to stop the seizure with an oral medication嘗試以口服藥物停止癲癇發作
- DTurn the client to a side-lying position✓ 正解將病人轉為側臥姿勢
癲癇發作(Seizure)時的護理核心是「保護病人免受二次傷害」及「維持呼吸道通暢」。在發作過程中,絕對禁止束縛肢體,因為強行約束可能導致骨折或肌肉拉傷。此外,絕不可強行將任何物品(如壓舌板)塞入病人口中,這極易導致牙齒斷裂或阻塞氣道。將病人側臥(Side-lying position)是正確的處置,能利用重力使口中分泌物流出,防止吸入性肺炎(Aspiration pneumonia)。
During a seizure, the core of nursing care is to protect the client from secondary injury and to maintain a patent airway. Restraining the extremities during a seizure is absolutely contraindicated, because forced restraint may cause fractures or muscle strains. In addition, no object (such as a tongue blade) should ever be forced into the client's mouth, as this can easily fracture teeth or obstruct the airway. Placing the client in a side-lying position is the correct intervention; it uses gravity to allow oral secretions to drain and prevents aspiration pneumonia.