護理師照護一位有癲癇病史的病人，下列哪些護理措施應納入照護計畫？（選所有適合的）

癲癇（Seizures）是大腦神經細胞異常、過度同步放電所引起的暫時性功能障礙。有癲癇病史的病人，其照護計畫應著重於預防癲癇發作、確保發作時的安全，以及發作後的照護。 核心原則是「保護病人安全」與「維持呼吸道通暢」。正確答案 B, C, D, E 都是針對發作時的保護措施。維持癲癇預防措施（Seizure precautions, B）是基礎，包括移除周圍危險物品、備好氧氣和抽痰設備等。發作時將病人側臥（Place the client on their side, C）有助於防止舌後倒阻塞呼吸道，並讓分泌物或嘔吐物順暢流出，預防吸入性肺炎。清除環境中的硬物（Clear the environment of hard objects, D）可避免病人在抽搐時撞擊受傷。解開緊身衣物（Loosen clothing around the client's neck, E）能減輕對頸部的壓迫，確保呼吸道暢通。 錯誤選項 A（床邊放置壓舌板）是過時且危險的做法。過去認為可防止咬傷舌頭，但實際上可能導致病人將壓舌板咬碎、誤吸，或造成牙齒損傷、顎骨骨折。現代癲癇照護不建議常規放置壓舌板於床邊。

Seizures are transient functional disturbances caused by abnormal, excessive, and synchronous discharges of cerebral neurons. For a client with a history of seizures, the plan of care should focus on preventing seizures, ensuring safety during a seizure, and providing post-ictal care. The core principles are "protect the client's safety" and "maintain airway patency." Correct answers B, C, D, and E are all protective measures during a seizure. Maintaining seizure precautions (B) is fundamental and includes removing surrounding hazards and having oxygen and suction equipment ready. Placing the client on their side during a seizure (C) helps prevent the tongue from falling back and obstructing the airway, allows secretions or vomitus to drain freely, and prevents aspiration pneumonia. Clearing the environment of hard objects (D) prevents injury from striking nearby items during convulsions. Loosening clothing around the client's neck (E) reduces pressure on the neck and helps keep the airway patent. Incorrect option A (keeping a padded tongue blade at the bedside) is an outdated and dangerous practice. It was once thought to prevent tongue biting, but in reality it may cause the client to bite the blade apart and aspirate fragments, or to sustain dental injuries or jaw fractures. Contemporary seizure care does not recommend routinely placing a tongue blade at the bedside.