NurslixJournal
安全與感染控制 · MEDIUM · MCQ

護理師照護一位有癲癇病史的病人。當病人發生全身強直陣攣性抽搐(Tonic-clonic seizure)時,哪項護理措施為優先?

A nurse is caring for a client with a history of seizures. Which nursing action is priority during an active tonic-clonic seizure?

  • AInsert a padded tongue blade
    插入包覆軟墊的壓舌板
  • BAdminister oral anticonvulsant medication
    給予口服抗癲癇藥物
  • CPlace the client in a side-lying position✓ 正解
    將病人置於側臥姿勢
  • DRestrain the client's extremities
    約束病人的四肢
Explanation · 中文詳解

在癲癇發作(Tonic-clonic seizure)期間,護理師的首要任務是保護病人免於受傷並確保呼吸道暢通。側臥位(Recovery position)能利用重力防止舌頭後墜阻塞呼吸道,並讓口腔內的分泌物、口水或嘔吐物順利流出,避免發生吸入性肺炎。在發作過程中,禁止強行固定病人或塞入任何物品,這些行為極易造成骨折或牙齒損傷。

During a tonic-clonic seizure, the nurse's first priority is to protect the client from injury and maintain a patent airway. The side-lying (recovery) position uses gravity to prevent the tongue from falling back and obstructing the airway and allows oral secretions, saliva, or vomitus to drain out of the mouth, preventing aspiration pneumonia. During the seizure, never forcibly restrain the client or insert any object into the mouth, as these actions can easily cause fractures or dental injury.

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