護理師督導助理人員(AP)照護癲癇病史的病人。AP 的哪項行為需要護理師立即介入?
A nurse is supervising an assistive personnel (AP) providing care for a client with a history of seizures. Which action by the AP requires immediate intervention by the nurse?
- ATurning the client to the side during the seizure activity在癲癇發作期間將病人轉向側臥
- BLoosening the clothing around the client's neck鬆開病人頸部的衣物
- CPlacing a padded tongue blade in the client's mouth during a seizure✓ 正解在癲癇發作期間將包紮過的壓舌板放入病人口中
- DClearing the area of sharp or hard objects清除區域內的尖銳或硬物
癲癇發作(Seizure)時的護理重點在於「保護病人安全」與「維持呼吸道暢通」。現代護理指引已明確禁止將任何異物(包括壓舌板、湯匙、手指)塞入病人嘴中,因為這極易導致牙齒斷裂、軟組織損傷,甚至因誤吞異物造成呼吸道阻塞。正確做法是移除周邊危險物品、保護頭部、讓病人側臥以利分泌物引流,並監測發作時間與型態。
The priorities during a seizure are to protect the client's safety and maintain a patent airway. Current nursing guidelines explicitly prohibit placing any object (including tongue blades, spoons, or fingers) into the client's mouth, because doing so can easily cause dental fractures, soft tissue injury, or airway obstruction from inhaled foreign bodies. The correct actions are to remove surrounding hazards, protect the head, position the client on their side to facilitate drainage of secretions, and monitor the duration and pattern of the seizure.