— 照護管理 · MEDIUM · MCQ —
護理師進入病房發現病人癲癇發作後倒在地上。護理師應優先採取何種措施？
A nurse enters a room and finds a client on the floor following a seizure. Which action should the nurse take first?
- AAssess airway and breathing✓ 正解評估呼吸道與呼吸
- BPlace the client on their side將病人置於側臥姿勢
- CCall for help尋求協助
- DAdminister an anticonvulsant medication給予抗癲癇藥物
— Explanation · 中文詳解 —
依據 ABC 評估原則，病人倒地後首要目標是確保呼吸道通暢。癲癇後可能發生舌後墜或呼吸道阻塞，優先評估呼吸狀態，隨後才是側臥以防止吸入性肺炎。呼救（C）是後續動作，而給藥（D）需由醫師醫囑執行，非第一行動。
Based on the ABC assessment principles, the priority after the client falls is to ensure airway patency. After a seizure, the tongue may fall back or the airway may become obstructed, so assessing the respiratory status comes first, followed by side-lying positioning to prevent aspiration. Calling for help (C) is a subsequent action, and administering medication (D) requires a provider's order and is not the first action.
✦ 台美臨床差異
台灣與美國臨床緊急處理原則一致，皆遵循 ABC 評估順序，但在呼救上台灣多使用護理呼叫鈴。