在病人癲癇發作時，護理師應採取哪些措施以確保安全？（選所有適合的）
Which actions should the nurse take to ensure client safety during a seizure? (Select all that apply.)
- ATurn the client to a side-lying position✓ 正解將病人轉為側臥姿勢
- BInsert a padded tongue blade into the mouth將包紮過的壓舌板置入口中
- CLoosen restrictive clothing around the neck✓ 正解鬆開頸部周圍限制性衣物
- DClear the surrounding area of hazardous objects✓ 正解清除周圍危險物品
- EAttempt to restrain the client's extremities嘗試約束病人四肢
癲癇發作時的護理重點為「防止受傷」與「維持呼吸道通暢」。護理師應保持冷靜，確保個案頭部安全並移除周遭危險物。側臥位可藉由重力幫助口腔分泌物與嘔吐物流出，預防吸入性肺炎。切記，現代護理準則嚴禁強行塞入任何物品（包括壓舌板）至發作中個案的口中，以免造成牙齒斷裂或阻塞呼吸道，亦不應束縛其四肢，以免造成肌肉撕裂或骨折。
During a seizure, the focus is preventing injury and maintaining a patent airway. The nurse should turn the client to the side (recovery position) so secretions and vomitus drain by gravity to prevent aspiration, loosen restrictive clothing around the neck, and clear the surrounding area of hazardous objects. Current standards strictly prohibit inserting any object (including padded tongue blades) into the mouth—this can break teeth and obstruct the airway. Restraining extremities can cause fractures or soft tissue injury.
在美國臨床實務中，極度強調「Do Not Restrain」與「Nothing in the Mouth」，NCLEX 考試對此非常嚴格，與台灣部分傳統臨床做法可能存在觀念落差，務必遵循最新實證指引。