— 生理適應 · EASY · SATA —
護理師照護一位有癲癇病史的病人，應採取哪些措施？（選所有適合的）
A nurse is caring for a client with a history of seizures. What interventions should be implemented? (Select all that apply.)
- AKeep the side rails up and padded✓ 正解拉起床欄並加裝軟墊。
- BMaintain a suction setup at the bedside✓ 正解在床邊準備抽吸裝置。
- CPlace a tongue blade in the mouth during a seizure在發作期間將壓舌板放入口中。
- DTurn the client to the side during a seizure✓ 正解在發作期間將病人轉為側臥。
- EDocument the duration and characteristics of the seizure✓ 正解記錄發作的持續時間和特徵。
— Explanation · 中文詳解 —
癲癇發作時的護理核心在於「安全防護」與「呼吸道維持」。預防病人因發作時肢體抽動而跌落床下，並確保發作後呼吸道暢通是優先事項。現代護理實務嚴格禁止在發作中強行撐開病人下顎或放入任何物體（如壓舌板），以免造成牙齒斷裂或阻塞呼吸道。詳細記錄發作過程（時間、肢體對稱性、意識狀態）對於診斷與後續藥物調整至關重要。
Seizure precautions focus on patient safety and maintaining a patent airway. Side rails should be padded to prevent injury, and a suction setup must be available to manage secretions. During a seizure, the client should be turned to the side to prevent aspiration, and detailed documentation of the event is vital for ongoing neurological management.