— 照護管理 · MEDIUM · SATA —
護理師正為一位有癲癇病史的病患規劃照護計畫，應包含哪些措施？（選所有適合的）
The nurse is caring for a client with a history of seizures. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- AKeep a suction setup at the bedside✓ 正解在床邊準備抽吸設備
- BEnsure side rails are padded✓ 正解確保床欄有軟墊保護
- CRestrain the client during a seizure to prevent injury在癲癇發作期間約束病人以防止受傷
- DMaintain an IV access✓ 正解維持靜脈通路
- EPlace a tongue blade in the mouth during a seizure在癲癇發作期間將舌片放入口中
— Explanation · 中文詳解 —
癲癇照護的核心是維持安全與呼吸道通暢。放置抽吸設備（A）與軟墊護欄（B）是標準安全防護；建立靜脈路徑（D）以便緊急給藥。不可約束病患（C），因為強烈肌肉抽動會造成骨折；不可放壓舌板（E），以免斷裂造成呼吸道阻塞或牙齒損傷。
The core of seizure care is maintaining safety and a patent airway. Bedside suction (A) and padded side rails (B) are standard protective measures, and IV access (D) is needed for emergency medication administration. The client should never be restrained (C), as forceful muscle contractions can cause fractures, and no tongue blade should be inserted (E), since it may break and obstruct the airway or damage teeth.
✦ 台美臨床差異
國際護理準則已明確禁止口中放置異物，台灣臨床護理教育亦已廣泛更新此觀念。