— 降低風險 · MEDIUM · SATA —
護理師為有癲癇病史的病人規劃照護。應實施哪些護理措施以確保病人安全？（選所有適合的）
A nurse is planning care for a client with a history of seizures. Which nursing interventions should be implemented to ensure client safety? (Select all that apply.)
- AKeep a suction setup at the bedside✓ 正解在床邊準備抽吸裝置
- BPad the side rails of the bed✓ 正解為床欄加襯墊
- CRestrain the client during the seizure在發作期間約束病人
- DMaintain the client in a side-lying position✓ 正解使病人保持側臥姿勢
- EInsert an oral airway during the seizure在發作期間插入口腔通氣管
— Explanation · 中文詳解 —
癲癇發作時的護理核心在於「保護病人免於傷害」與「維護呼吸道通暢」。護理措施應著重於環境安全準備，而非在發作當下進行干預。正確措施包括：準備抽吸設備以應對發作後的唾液積聚；加裝床欄襯墊以防抽搐撞傷；將病人側臥以利分泌物流出，預防吸入性肺炎。切忌在發作時進行侵入性操作或約束，以免造成病人骨折、牙齒斷裂或氣道損傷。
Seizure care centers on protecting the client from harm and maintaining airway patency. Have suction equipment ready, pad side rails to prevent trauma from limb movements, and position the client side-lying to allow secretions to drain and prevent aspiration. Never restrain the client or insert anything into the mouth during a seizure—these actions cause fractures, dental injury, or airway obstruction.