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照護管理 · MEDIUM · SATA

護理師照護有癲癇病史的病人,應採取哪些措施?(選所有適合的)

A nurse is caring for a client with a history of seizures. Which actions should the nurse include in the plan of care? (Select all that apply.)

  • AKeep a suction setup at the bedside✓ 正解
    在床旁準備抽吸設備
  • BPad the side rails of the bed✓ 正解
    為床欄加裝軟墊
  • CPlace a padded tongue blade in the mouth during a seizure
    在發作期間將壓舌板置入口中
  • DEnsure O2 equipment is readily available✓ 正解
    確保氧氣設備隨時可用
  • ELoosen restrictive clothing around the neck✓ 正解
    鬆開頸部的緊身衣物
Explanation · 中文詳解

癲癇(Seizure)發作時的護理重點在於「保護病人免受外傷」與「維持呼吸道暢通」。護理師應移除周圍危險物品、保護頭部,並在發作後採取側臥姿勢(Recovery Position)以防吸入性肺炎。絕對禁止強行將異物(如壓舌板)放入病人口中,以免導致牙齒斷裂或阻塞呼吸道。床邊備妥抽吸設備與氧氣是標準的安全設施,應列入護理計畫中。

During a seizure, the nursing focus is to protect the client from injury and maintain airway patency. The nurse should remove nearby hazards, protect the head, and place the client in the recovery (side-lying) position after the event to prevent aspiration. Forcing objects (e.g., a padded tongue blade) into the mouth is strictly contraindicated due to risk of dental injury or airway obstruction. Bedside suction and oxygen are standard safety equipment that must be included in the care plan.

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