— 生理適應 · EASY · MCQ —
一位病人正經歷強直陣攣性發作,護理師的首要介入措施為何?
A client is experiencing a tonic-clonic seizure. What is the nurse's priority intervention?
- AInsert a bite block置入咬合板
- BAdminister IV diazepam靜脈注射地西泮
- CTurn the client to the side✓ 正解將病人轉為側臥
- DRestrain the client's extremities約束病人四肢
— Explanation · 中文詳解 —
在強直陣攣性發作(Tonic-Clonic Seizure)期間,護理師的首要任務是維持呼吸道通暢(Airway)並預防受傷(Safety)。將病人側臥(Side-lying)可防止舌頭後墜導致呼吸道阻塞,並利於口腔分泌物或嘔吐物流出,避免誤吸。任何強行限制動作或放入異物的行為都可能造成骨折或牙齒斷裂,應嚴格禁止。
During a tonic-clonic seizure, the nurse's priorities are maintaining airway patency and preventing injury. Turning the client to the side prevents posterior tongue displacement from obstructing the airway and allows secretions or vomitus to drain, preventing aspiration. Forcibly restraining limbs or inserting objects into the mouth can cause fractures or dental injury and must be avoided.