— 安全與感染控制 · MEDIUM · MCQ —
下列哪項評估發現需要護理師立即執行癲癇發作預防措施？
Which assessment finding requires the nurse to immediately implement seizure precautions?
- AA client with type 2 diabetes mellitus患有第二型糖尿病的個案
- BA client with a history of alcohol withdrawal✓ 正解有酒精戒斷史的個案
- CA client with elevated cholesterol levels膽固醇指數偏高的個案
- DA client with a new diagnosis of hypertension新診斷為高血壓的個案
— Explanation · 中文詳解 —
酒精戒斷（Alcohol Withdrawal）病人因酒精對腦部神經傳導物質的影響，在戒斷期間極易出現癲癇發作（Withdrawal Seizures），特別是在停酒後的 12 至 48 小時內。護理師需評估病人戒斷症狀，並預先準備癲癇防護措施，包括拉起床欄、準備好氧氣與抽吸設備，以確保發作時的安全。
Alcohol withdrawal alters CNS neurotransmitters and predisposes to withdrawal seizures, especially 12-48 hours after the last drink. The nurse must assess withdrawal symptoms and implement seizure precautions—raising side rails and ensuring oxygen and suction are readily available.