護理師照顧一位正處於強直陣攣性發作的病人。護理師應採取哪些行動？（選所有適合的）
A nurse is caring for a client experiencing a tonic-clonic seizure. Which actions should the nurse perform? (Select all that apply.)
- AProtect the client's head from injury✓ 正解保護病人头部免受傷害
- BInsert a padded tongue blade into the mouth將包墊的舌壓板置入口中
- CTime the duration of the seizure✓ 正解記錄發作持續時間
- DTurn the client to the side✓ 正解將病人轉為側臥
- ERestrain the client's limbs to prevent injury約束病人四肢以預防受傷
強直陣攣性發作（Tonic-clonic seizure）期間，護理師的首要任務是病人安全與氣道保護。發作時應移除周遭危險物品，保護頭部以防撞擊導致腦損傷。將病人側臥可促進分泌物引流，防止舌頭後墜或嘔吐物吸入造成窒息。記錄發作時間有助於醫師評估藥物需求與發作嚴重程度。切記不可強行束縛，以免造成骨折或肌肉損傷，亦不可嘗試撬開牙關，以免對牙齒或護理人員手指造成傷害。
During a tonic-clonic seizure, the nurse's primary task is to ensure patient safety and protect the airway. Hazards in the surroundings should be removed, and the head should be protected to prevent impact-related brain injury. Placing the client in a lateral position promotes drainage of secretions and prevents the tongue from falling back or aspiration of vomitus, which could cause asphyxia. Documenting the duration of the seizure assists the physician in evaluating medication needs and seizure severity. The nurse should never forcibly restrain the client, as this may cause fractures or muscle injury, and should never try to pry open the jaw, as this can damage the teeth or injure the nurse's fingers.