護理師照護一位有癲癇發作史的病人。在全身性強直陣攣發作期間,哪項措施最優先?
A nurse is caring for a client with a history of seizures. Which intervention is the priority during a generalized tonic-clonic seizure?
- AInsert an oral airway插入口腔通氣管
- BRestrain the client's extremities約束病人四肢
- CAdminister IV lorazepam靜脈注射勞拉西泮
- DTurn the client to the side✓ 正解將病人轉為側臥
癲癇發作(seizure)期間,護理師的首要任務是保護病人免受外傷並確保呼吸道暢通。將病人轉向側臥位(side-lying position)能讓口腔內的分泌物自然流出,防止吸入性肺炎與呼吸道阻塞。過程中應移除病人周圍危險物品,禁止約束肢體,也不可強行放入口腔異物(如壓舌板),以免損壞牙齒或造成呼吸道阻塞。
During a seizure, the nurse's primary task is to protect the patient from injury and to maintain a patent airway. Turning the patient to a side-lying position allows oral secretions to drain naturally and prevents aspiration pneumonia and airway obstruction. During the seizure, dangerous objects around the patient should be removed; limbs should not be restrained; and foreign objects (such as a tongue blade) must not be forced into the mouth, in order to avoid damaging the teeth or obstructing the airway.