護理師照護一位正處於強直陣攣性癲癇發作的病人。下列哪些措施是適當的？（選所有適合的）
A nurse is caring for a client experiencing a tonic-clonic seizure. Which actions are appropriate? (Select all that apply.)
- ALoosen clothing around the client's neck✓ 正解鬆開個案頸部的衣物
- BInsert a bite block or tongue depressor插入咬塊或舌壓板
- CPlace the client on their side✓ 正解將個案置於側臥姿勢
- DRestrain the client's limbs to prevent injury約束個案的四肢以預防受傷
- ETime the duration of the seizure✓ 正解記錄發作的持續時間
癲癇發作照護原則為維護呼吸道通暢與預防外傷。鬆開衣物利於呼吸，側臥位可防止舌頭後墜與誤吸。嚴禁強行放入咬口器或壓舌板（易導致牙齒斷裂或吸入異物），絕對不可約束病人的四肢活動（易造成骨折）。需詳細記錄發作時間以評估是否有癲癇重積狀態。
The principles of seizure care are to maintain airway patency and prevent injury. Loosening clothing facilitates breathing, and a side-lying position prevents the tongue from falling back and aspiration. Forcibly inserting a bite block or tongue depressor is strictly forbidden (it can cause tooth fractures or aspiration of foreign bodies), and the client's limbs must never be restrained (which can cause fractures). Seizure duration must be timed carefully to assess for status epilepticus.
美國各醫療機構對癲癇照護有極嚴格的 protocol；台灣臨床對咬口器的舊式觀念雖已改善，但仍需不斷更新護理知識。