一位護理師正在接收入院一位有癲癇病史的病人。哪項安全措施是優先的?
A nurse is admitting a client with a history of seizures. Which safety measure is a priority?
- AAdministering anticonvulsant medication.給予抗癲癇藥物
- BPlacing the client in a restraints.將病人約束
- CKeeping the client NPO.維持病人禁食(NPO)
- DEnsuring a clear environment around the bed.✓ 正解確保病床周圍環境暢通無阻
癲癇(Seizure)病人照護的首要任務是「預防傷害」(Safety)。當病人發作時,護理師無法阻止發作,但可以透過移除周圍危險物品(如床邊桌、銳利物)來防止病人受傷。環境安全評估是入院時的第一要務,這包含了預防跌倒與碰撞。其他介入如給藥或約束,皆需在特定時機或醫囑下進行,並非入院時的優先安全防護措施。
The primary nursing priority for a client with seizures is injury prevention (safety). When a seizure occurs, the nurse cannot stop it, but can prevent injury by removing surrounding hazards (such as bedside tables and sharp objects). Assessment of environmental safety is the first priority at admission and includes fall and collision prevention. Other interventions such as medication administration or restraint application are performed only at specific times or with a physician's order and are not the priority safety measure at the time of admission.