— 生理適應 · MEDIUM · SATA —
針對癲癇大發作（僵直-陣攣發作）的病患，哪些護理介入是適當的？（選所有適合的）
Which of the following interventions are appropriate for a client experiencing a tonic-clonic seizure? (Select all that apply.)
- ATurn the client to their side✓ 正解將病人轉為側臥
- BPlace a padded tongue blade in the mouth在口中放置加墊的壓舌板
- CClear the area of hard objects✓ 正解清除周圍的硬物
- DAttempt to restrain the client's limbs嘗試約束病人的四肢
- ELoosen clothing around the neck✓ 正解鬆開頸部的衣物
— Explanation · 中文詳解 —
癲癇發作時護理核心為保護病人不受外傷及維持呼吸道通暢。將病人側臥可防止吸入性肺炎；移除硬物避免碰撞；鬆開緊身衣物利於呼吸。B 選項絕對禁止，以免造成牙齒斷裂或阻塞呼吸道；D 絕對禁止，強制束縛可能導致病人骨折。
During a tonic-clonic seizure, the primary nursing goals are to protect the client from injury and maintain a patent airway. Turning the client to the side prevents aspiration of secretions, while clearing the area of hard objects reduces the risk of trauma from flailing limbs. Loosening clothing around the neck facilitates breathing. Inserting objects into the mouth or restraining the client is contraindicated as it can cause injury or fractures.
✦ 台美臨床差異
台美臨床對於癲癇發作的「保護性處置」共識一致，皆強調不再使用壓舌板，並重視環境安全移除。