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生理適應 · EASY · MCQ

護理師照顧有癲癇病史的病人。為確保病人安全,下列何者應列為優先?

A nurse is caring for a client with a history of seizures. What should the nurse prioritize to ensure patient safety?

  • AMaintain a patent airway and provide suction if needed✓ 正解
    維持呼吸道通暢,必要時進行抽吸
  • BAdminister anticonvulsant medication every 2 hours
    每 2 小時給予抗癲癇藥物
  • CKeep a padded tongue blade at the bedside
    在床邊備妥包布壓舌板
  • DRestrain the client's limbs to prevent injury
    約束病人四肢以預防受傷
Explanation · 中文詳解

癲癇(Seizure)發作時,護理師的首要任務是確保病人呼吸道通暢(Airway)。發作期間應保護病人頭部,移開周圍危險物品,並在發作後給予側臥以利呼吸道分泌物排出。現代護理實務嚴格禁止強行壓制病人肢體,也不得將壓舌板或任何物體放入嘴中,以免導致牙齒斷裂或呼吸道阻塞。安全照護強調「維持生命跡象」勝於「限制動作」。

During a seizure, the nurse's first priority is to ensure that the client's airway remains patent. During the seizure, the nurse should protect the head, remove surrounding hazards, and afterwards turn the client side-lying to facilitate drainage of oral secretions. Current nursing practice strictly prohibits forcibly restraining the limbs or placing a tongue blade or any object in the mouth, to prevent tooth fractures or airway obstruction. Safe care emphasizes maintaining vital functions rather than restricting movement.

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