— 生理適應 · MEDIUM · MCQ —
病人發生癲癇發作，護理師應優先採取何種行動？
A client is experiencing a seizure. Which action should the nurse take first?
- ARestrain the client's limbs約束病患四肢
- BInsert a bite block插入咬口器
- CProtect the client from injury✓ 正解保護病患免受傷害
- DCall the physician通知醫師
— Explanation · 中文詳解 —
癲癇發作時的護理優先順序為「安全（Safety）」。護理師的首要任務是保護病人免受周圍環境的傷害，例如移除危險物品、保護頭部。嚴禁強行約束或往病人口中塞入物體，因為這極易導致牙齒折斷、口腔黏膜受傷，甚至阻塞呼吸道。發作後應將病人轉為側臥（Recovery position），以確保呼吸道通暢，並監測生命徵象。
Nursing priority during a seizure is safety. The nurse's first task is to protect the patient from environmental injury, such as by removing hazardous objects and protecting the head. Forceful restraint and inserting any object into the patient's mouth are strictly prohibited, as these readily cause broken teeth, oral mucosal injury, and even airway obstruction. After the seizure, the patient should be turned to the lateral (recovery) position to ensure airway patency, and vital signs should be monitored.