— 生理適應 · EASY · MCQ —
一位病人正在經歷全身強直陣攣發作，護理師應優先採取哪項措施？
A client is experiencing a tonic-clonic seizure. Which action should the nurse take first?
- AInsert an oral airway置入口咽通氣道
- BTurn the client to the side✓ 正解將病人轉為側臥
- CAdminister an IV bolus of lorazepam靜脈推注勞拉西泮
- DRestrain the client's extremities約束病人四肢
— Explanation · 中文詳解 —
全身強直陣攣發作（Tonic-clonic seizure）時，護理師的首要任務是確保病人的呼吸道通暢（Airway）並防止受傷。將病人轉為側臥姿勢（復甦姿勢）可避免舌頭後墜阻塞呼吸道，並讓口腔內的分泌物或嘔吐物順利流出，防止吸入性肺炎。這符合 NCLEX 的安全優先原則，即在危急狀況下優先處理呼吸與安全。
During a tonic-clonic seizure, the nurse's first priority is to maintain airway patency and prevent injury. Turning the client to the side (recovery position) prevents the tongue from falling back and obstructing the airway, and allows oral secretions or vomitus to drain freely, preventing aspiration pneumonia. This aligns with the NCLEX principle of safety priority, which dictates that breathing and safety are addressed first in critical situations.