— 基本照護與舒適 · EASY · MCQ —
護理師照顧一位有癲癇病史的病人。下列哪項護理措施應優先執行？
A nurse is caring for a client with a history of seizures. What priority nursing action should be implemented?
- AClear the area of hard objects and protect the head✓ 正解清除周圍硬物並保護頭部
- BAdminister an oral sedative immediately立即給予口服鎮靜劑
- CPlace a padded tongue blade between the teeth將壓舌板置於牙齒之間
- DRestrain the client's extremities during the seizure在癲癇發作期間限制病人四肢
— Explanation · 中文詳解 —
癲癇發作時的護理重點在於保護病人安全。清除周邊危險物品並保護頭部可預防外傷。綑綁肢體（D）容易造成骨折；強行置入壓舌板（C）易傷及牙齒或導致呼吸道阻塞；發作時不可餵食或給藥（B），以免造成吸入性肺炎。
During a seizure, nursing priorities are client safety and airway protection. Clear the surrounding area of hard or dangerous objects and protect the head. Do not restrain limbs (causes fractures), do not place objects in the mouth (causes dental and airway trauma), and do not give anything by mouth during the seizure (risk of aspiration).
✦ 台美臨床差異
台美皆已摒棄在發作時使用壓舌板的舊觀念，重視環境安全。