— 照護管理 · HARD · MCQ —
一位有癲癇病史的病人出現左手臂局部抽搐。護理師應優先採取的行動為何？
A nurse is caring for a client with a history of seizures. The nurse notes the client is exhibiting focal jerking movements in the left arm. Which action is the priority?
- ACall the physician immediately立即通知醫師
- BAdminister IV lorazepam as prescribed依醫囑靜脈注射勞拉西泮
- CObserve and time the seizure activity✓ 正解觀察並記錄抽搐活動的時間
- DInsert a padded tongue blade into the mouth將包紮過的壓舌板置入口中
— Explanation · 中文詳解 —
針對癲癇發作，首要且關鍵的護理措施是觀察並記錄發作的型態、持續時間與受影響部位。這對於醫師後續診斷與調整抗癲癇藥物至關重要。選項 B 為發作持續過久或強直痙攣時的處置；C 已證實會導致病人口腔創傷，應嚴禁；A 則應在記錄完畢並確保病人安全後再執行。
The priority action is to observe and time the seizure activity to document its characteristics, which is essential for clinical management and diagnosis. Inserting objects into the mouth is contraindicated due to injury risk, and notifying the provider or administering medication occurs after ensuring safety and gathering necessary assessment data.
✦ 台美臨床差異
台美對癲癇發作的「壓舌板」禁令一致，但台灣臨床偶見老一輩醫師仍要求，需具備依循實證指引的專業判斷。