護理師為癲癇病史病人規劃照護,應包含哪些內容?(選所有適合的)
A nurse is planning care for a client with a history of seizures. Which interventions should the nurse include? (Select all that apply.)
- APad the side rails of the hospital bed✓ 正解為醫院病床的床欄加裝護墊
- BKeep a suction device ready in the room✓ 正解在病房內準備好抽痰設備
- CRestrain the client during the seizure to prevent injury癲癇發作時約束個案以防止受傷
- DEnsure oxygen equipment is available✓ 正解確保氧氣設備可用
- EPlace an oral airway in the client's mouth at the onset of seizure在癲癇發作開始時將口咽通氣管置入個案口中
癲癇安全照護首重預防傷害與維持呼吸道通暢。放置床欄護墊可防碰撞,準備抽痰機與氧氣以應對發作後的呼吸道清理需求。C 選項絕對錯誤,發作時不可約束,以免造成骨折或組織受損。E 選項過時且危險,強行放入異物易導致病人口腔受傷或牙齒斷裂掉入呼吸道。
Safe nursing care for seizures focuses primarily on preventing injury and maintaining airway patency. Padded side rails are placed to prevent traumatic impact, and suction equipment and oxygen are prepared to address post-ictal airway-clearance needs. Option C is absolutely incorrect: the patient must not be restrained during a seizure, as this may cause fractures or tissue injury. Option E is outdated and dangerous; forcing a foreign object into the mouth may injure the oral cavity or break teeth that could then be aspirated into the airway.
美台臨床對於癲癇照護指引一致,皆嚴禁發作期放入異物及約束。