— 生理適應 · EASY · MCQ —
一位病人正發生強直陣攣性發作（tonic-clonic seizure）。下列何者為護理師最高優先級的行動？
A client is experiencing a tonic-clonic seizure. Which nursing action is the highest priority?
- AAdminister IV lorazepam靜脈注射勞拉西泮
- BInsert a padded tongue blade插入包墊的舌壓板
- CRestrain the client's extremities約束病人的四肢
- DProtect the client from injury✓ 正解保護病人免受傷害
— Explanation · 中文詳解 —
癲癇發作時，護理重點在於保護病人安全（如移開尖銳物、支撐頭部）。絕對不可約束四肢（C），會增加骨折風險；不可放入任何東西入嘴（B），會導致牙齒斷裂或呼吸道阻塞。給藥（A）是後續醫療處置，並非發作當下的最優先事項。
During a seizure, the priority is protecting the client from injury (e.g., moving sharp objects away, supporting the head). Restraining extremities (C) increases fracture risk; placing anything in the mouth (B) risks dental injury or airway obstruction. Medication administration (A) is secondary to immediate safety.
✦ 台美臨床差異
台灣臨床護理教育已更新不放入壓舌板或牙墊的觀念，與美國護理準則一致。