護理師照護一位有癲癇病史的病人。發作期間應採取哪些措施以確保安全？（選所有適合的）
A nurse is caring for a client with a history of seizures. Which interventions should the nurse implement during a seizure to ensure safety? (Select all that apply.)
- APlace the client on their side to prevent aspiration✓ 正解將病人置於側臥位以防止吸入
- BInsert a padded tongue blade to prevent tongue biting插入包紮過的壓舌板以防止咬舌
- CRemove harmful objects from the immediate environment✓ 正解移除周圍環境中的危險物品
- DRestrain the client's extremities to prevent injury約束病人的四肢以防止受傷
- EDocument the duration and characteristics of the seizure✓ 正解記錄發作的持續時間和特徵
癲癇發作時的優先護理原則是保護病人免受二次傷害，重點為環境安全與呼吸道通暢。需採側臥位防嗆咳、移開危險物品、詳細記錄發作過程與時間。B 選項錯誤，絕對禁止將東西放入口中，會導致牙齒斷裂或阻塞呼吸道。D 選項錯誤，限制活動會導致骨折或肌肉損傷。
The priority of nursing care during a seizure is to protect the patient from secondary injury, focusing on environmental safety and a patent airway. The patient should be placed in a side-lying position to prevent aspiration, hazardous objects should be moved away, and the seizure course and timing should be carefully recorded. Option B is incorrect: placing anything in the patient's mouth is absolutely forbidden, as it can break teeth or obstruct the airway. Option D is incorrect: restraining the patient's movements may cause fractures or muscle injury.
兩國對癲癇發作的護理共識高度一致，禁止強制約束與禁止放置口中物均為護理教育的核心。