— 降低風險 · MEDIUM · SATA —
一位有癲癇病史的病人，護理師應採取哪些措施以維護病人安全？（選所有適合的）
A nurse is caring for a client with a history of seizures. Which interventions are appropriate to maintain client safety? (Select all that apply.)
- AKeep the side rails up and padded✓ 正解保持床欄拉起並加裝軟墊
- BMaintain suction equipment at the bedside✓ 正解在床邊準備抽吸設備
- CInsert a padded tongue blade during the seizure在發作期間插入加墊的壓舌板
- DLoosen restrictive clothing around the neck✓ 正解鬆開頸部周圍緊束的衣物
- EPlace the client on their side to prevent aspiration✓ 正解將病人置於側臥姿勢以防止吸入
— Explanation · 中文詳解 —
癲癇護理重點在於防止傷害與維持呼吸道。床欄加軟墊可防止碰撞；床邊備有抽吸設備以防嘔吐阻塞；側臥姿勢能預防吸入性肺炎；鬆開緊身衣物利於呼吸。嚴禁在癲癇發作時強行放入壓舌板，這會導致病人口腔黏膜或牙齒損傷。
Care for seizure clients focuses on preventing injury and maintaining the airway. Padded side rails prevent collision injuries; suction equipment at the bedside addresses vomitus or secretions; lateral positioning prevents aspiration pneumonia; and loosening tight clothing facilitates breathing. Inserting a tongue blade during a seizure is strictly prohibited, as it can damage the oral mucosa or teeth.
✦ 台美臨床差異
兩地護理標準皆一致，強調發作時保護而非強行固定或放入異物。台灣臨床護理師常需教育家屬此觀念以防錯誤處置。