— 降低風險 · EASY · MCQ —
護理師正在評估一位正在經歷癲癇發作的病人。護理師應首先採取什麼行動？
A nurse is assessing a client who is experiencing a seizure. Which action should the nurse take first?
- ARestrain the client's limbs約束病人的四肢
- BTurn the client onto their side✓ 正解將病人轉為側臥
- CPlace a padded tongue blade in the client's mouth在病人口中放入包墊的壓舌板
- DDocument the seizure activity記錄癲癇發作情況
— Explanation · 中文詳解 —
癲癇發作（Seizure）時，護理師的第一優先任務是確保病人的呼吸道通暢（Airway）並保護病人不受外傷。將病人側臥（Lateral position）可以防止舌頭後縮阻塞氣道，並有助於口腔內分泌物或嘔吐物流出，避免引發吸入性肺炎。在發作過程中，不應強行固定肢體或塞入異物，以免造成骨折或牙齒損傷。
During a seizure, the nurse's first priority is to ensure airway patency and to protect the patient from injury. Placing the patient in the lateral position prevents the tongue from falling back and obstructing the airway, and allows oral secretions or vomitus to drain out, reducing the risk of aspiration pneumonia. During the seizure, the limbs must not be forcibly restrained and no object should be inserted into the mouth, as these can cause fractures or dental injury.