一位病人正發生強直陣攣性癲癇發作。護理師應採取哪些行動？（選所有適合的）
A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? (Select all that apply.)
- AInsert a padded tongue blade into the mouth將加襯墊的舌片插入口中
- BTurn the client to the side✓ 正解將病人轉為側臥
- CClear the area of hard objects✓ 正解清除區域內的硬物
- DLoosen restrictive clothing✓ 正解鬆開限制性衣物
- ERestrain the client's limbs to prevent injury約束病人的四肢以防止受傷
癲癇發作時的護理重點為預防二次創傷。首要任務是保護頭部與移開周圍硬物（C），將病人側臥（B）以利唾液分泌物排出並預防吸入性肺炎，同時鬆開衣物（D）以利呼吸。絕對禁止在發作中強行放入異物（A）或約束肢體（E），以免造成骨折或牙齒斷裂。
The nursing focus during a seizure is to prevent secondary injury. The primary tasks are to protect the head and clear surrounding hard objects (C), turn the client to the side (B) to facilitate drainage of oral secretions and prevent aspiration pneumonia, and loosen clothing (D) to facilitate breathing. It is strictly prohibited to forcibly insert any object into the mouth during a seizure (A) or to restrain the limbs (E), as this may cause fractures or dental injury.
在美國與台灣的護理教育中，皆已明確禁止發作時插入壓舌板，但在基層照護執行面仍需加強衛教。