— 照護管理 · MEDIUM · MCQ —
護理師照顧一位有癲癇病史的病人，癲癇發作時的優先措施為何？
A nurse is caring for a client with a history of seizures. What should be the nurse's priority during a seizure?
- AAdminister an oral anticonvulsant medication給予口服抗癲癇藥物
- BRestrain the client's limbs to prevent injury約束病人的四肢以預防受傷
- CInsert a padded tongue blade into the mouth將包紮過的舌壓器置入口中
- DTurn the client to the side and clear the area✓ 正解將病人轉為側臥並清除周圍區域
— Explanation · 中文詳解 —
癲癇發作時，首重維護病人安全。應將病人側臥以利口鼻分泌物排出，避免吸入性肺炎，同時移開身旁尖銳物以防外傷。嚴禁約束病人的肢體，會造成骨折；嚴禁往口中放置任何異物，會導致牙齒斷裂或呼吸道阻塞；發作時絕對不可經口給藥，有窒息風險。
The priority during a seizure is to turn the client to the side and clear the area to protect the airway and prevent aspiration of secretions. Restraining limbs, inserting objects into the mouth, or administering oral medications are dangerous actions that can cause injury, fractures, or airway obstruction.
✦ 台美臨床差異
台美臨床急救準則對癲癇發作處置方式完全一致，均強調「不約束、不塞物、側臥」。