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照護管理 · EASY · MCQ

護理師督導照服員照顧有癲癇病史的病人。照服員的哪項行為需要護理師立即介入?

A nurse is supervising an assistive personnel (AP) providing care to a client with a history of seizures. Which action by the AP requires the nurse to intervene immediately?

  • ATurning the client onto their side
    將個案轉為側臥
  • BPlacing a padded tongue blade in the client's mouth✓ 正解
    在個案口中放置軟墊壓舌板
  • CLoosening clothing around the client's neck
    鬆開個案頸部的衣物
  • DClearing the area of sharp objects
    清除區域內的尖銳物品
Explanation · 中文詳解

癲癇發作時的護理核心是「保護病人安全」與「維持呼吸道通暢」。現代護理指引已明確指出,嚴禁在發作期間向病人口中強行放置任何物體(如壓舌板、湯匙、手指),這會導致牙齒斷裂、軟組織嚴重撕裂傷,甚至造成呼吸道阻塞。護理師應督導照服員移開周邊危險物,並於發作後將病人置於側臥位(Recovery position)。

The core of nursing care during a seizure is 'patient safety first' and 'maintaining a patent airway.' Modern nursing guidelines clearly state that forcing any object (such as a tongue depressor, spoon, or finger) into the client's mouth during a seizure is strictly prohibited, as this may cause broken teeth, severe soft-tissue lacerations, and even airway obstruction. The nurse should direct the nursing assistant to move surrounding hazards away and, after the seizure, place the client in the lateral recovery position.

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