— 生理適應 · EASY · MCQ —
護理師照護一位正處於強直陣攣發作的病人，期間應採取什麼行動？
A nurse is caring for a client experiencing a tonic-clonic seizure. Which action should the nurse take during the event?
- AInsert a tongue blade to prevent airway obstruction插入壓舌板以防止呼吸道阻塞
- BAttempt to open the airway with a jaw-thrust maneuver嘗試以下巴推舉法打開呼吸道
- CPlace the client in a side-lying position✓ 正解將病人置於側臥姿勢
- DRestrain the client's extremities to prevent injury約束病人四肢以防止受傷
— Explanation · 中文詳解 —
發作期間首要任務是維護安全。將病人側臥可防止唾液吸入導致誤吸，維持呼吸道通暢。嚴禁強行張口插入壓舌板，以免造成口腔損傷或斷裂造成異物吸入；約束四肢可能造成骨折；強行打開呼吸道在發作當下無效且具危險性。
Safety is the priority during a seizure. Placing the client side-lying prevents aspiration of saliva and maintains airway patency. Never force a tongue blade into the mouth to avoid oral trauma or aspiration of broken pieces; restraining limbs may cause fractures; forcing airway maneuvers during the seizure is ineffective and dangerous.
✦ 台美臨床差異
台美臨床指引皆強調側臥法，但在執行細節上，美國護理教育更強調「不要讓病人受傷」大於「限制發作」，台灣臨床則常需注意病床欄杆是否有鋪軟墊。