護理師督導照服員(AP)照顧一位有癲癇病史的病人。下列哪項照服員的行為需要護理師立即介入?
A nurse is supervising an assistive personnel (AP) providing care to a client with a history of seizures. Which action by the AP requires immediate intervention by the nurse?
- APadding the side rails of the bed在床欄上墊襯墊
- BPlacing a tongue blade in the client's mouth during a seizure✓ 正解在病患癲癇發作期間將舌片放入口中
- CLoosening the client's restrictive clothing鬆開病患緊身的衣物
- DTurning the client to their side during a seizure在病患癲癇發作期間將其翻轉至側臥
癲癇發作時,護理師應確保病人安全,重點在於維持呼吸道通暢與預防外傷。將物品(如壓舌板或手指)置入病人口中會導致牙齒斷裂、軟組織損傷,甚至導致呼吸道阻塞,絕不可執行。正確措施為將病人側臥(以利分泌物引流)、保護頭部、鬆開領口,並記錄發作時間與特徵。若照服員錯誤執行,護理師需立即介入並重新教育正確的急救原則。
During a seizure, the nurse must ensure client safety with an emphasis on maintaining a patent airway and preventing injury. Placing an object (such as a tongue blade or a finger) into the client's mouth can cause dental fractures, soft-tissue injury, or even airway obstruction and must never be performed. Correct measures include positioning the client side-lying (to facilitate drainage of secretions), protecting the head, loosening clothing at the neck, and documenting the time and characteristics of the seizure. If the assistive personnel performs an incorrect action, the nurse must intervene immediately and re-educate the AP on the correct first-aid principles.