— 安全與感染控制 · MEDIUM · MCQ —
病人發生強直陣攣性癲癇發作，護理師優先採取的行動為何？
A client is experiencing a tonic-clonic seizure. What is the nurse's priority action?
- AProtect the client's head from injury✓ 正解保護病人頭部免受傷害
- BRestrain the client's arms to prevent flailing約束病人手臂以防止揮舞
- CPlace a tongue blade in the client's mouth將壓舌板置入病人口中
- DAttempt to stop the seizure with medication嘗試用藥物停止癲癇發作
— Explanation · 中文詳解 —
癲癇發作時，護理師的首要任務是確保病人安全（Safety）。強直陣攣性發作（Tonic-clonic seizure）涉及全身肌肉強直與陣攣，病人無法控制肢體。護理師應採取保護措施，避免病人因劇烈撞擊或動作導致頭部受傷或骨折。絕對不可嘗試將任何物品放入病人口中，亦不可強行約束肢體，這些行為反而會造成物理性傷害。
During a seizure, the nurse's primary task is ensuring safety. Tonic-clonic seizures involve generalized muscle stiffening and convulsion; the client cannot control limbs. The nurse should take protective measures to prevent head trauma or fractures. Never place anything in the client's mouth or attempt to physically restrain limbs, as these actions cause harm.
✦ 台美臨床差異
台灣部分舊式臨床觀念有時仍會提及放置壓舌板，但在美國 NCLEX 考試中，這被視為嚴重的禁忌操作（Contraindicated）。