一位有癲癇病史的病人發生強直陣攣性發作，護理師的首要行動為何？
A nurse is caring for a client with a history of seizure disorder. What is the priority nursing action during a tonic-clonic seizure?
- ARestrain the client's extremities to prevent injury限制病人的四肢以防止受傷
- BInsert a padded tongue blade to prevent tongue biting插入包有軟墊的壓舌板以防止咬舌
- CAttempt to open the client's mouth to clear secretions嘗試張開病人的嘴巴以清除分泌物
- DTurn the client to the side to maintain airway patency✓ 正解將病人轉為側臥以保持呼吸道通暢
癲癇發作時的護理核心在於「安全（Safety）」與「維持呼吸道通暢（Airway Patency）」。強直陣攣性發作（Tonic-Clonic Seizure）期間，病人會出現肌肉僵直與陣發性抽搐，此時首要任務是防止呼吸道阻塞及避免病人因撞擊而受傷。將病人側臥（Lateral position）可利用重力使口中分泌物或嘔吐物流出，防止吸入性肺炎（Aspiration pneumonia），並保持呼吸道開放。護理師應採取 ABC（Airway, Breathing, Circulation）原則，優先處理呼吸道問題。
During a tonic-clonic seizure, the priority is safety and maintaining airway patency. Turning the client to the side allows gravity to drain secretions, preventing aspiration. Avoid inserting anything into the mouth (risks dental and airway trauma) and never restrain the limbs (risks fractures). Use the ABC framework, with airway as the immediate concern.