— 生理適應 · EASY · MCQ —
病人發生強直陣攣性癲癇發作時，護理師的首要行動為何？
A client is experiencing a tonic-clonic seizure. Which nursing action is the priority?
- ATurn the client to the side✓ 正解將病人轉為側臥
- BRestrain the client's limbs約束病人四肢
- CAdminister IV lorazepam給予靜脈注射勞拉西泮
- DInsert an oral airway置入口腔通氣管
— Explanation · 中文詳解 —
強直陣攣性癲癇（Tonic-clonic seizure）發作時，護理師的最高指導原則是「病人安全（Patient Safety）」。優先執行側臥位（Recovery position），目的是防止嘔吐物或分泌物吸入導致窒息，並保持呼吸道通暢。絕對禁止約束肢體，以免造成骨折，也不可強行塞異物入嘴，以免牙齒斷裂造成氣道異物阻塞。
The priority nursing action during a tonic-clonic seizure is to turn the client to the side to prevent aspiration of secretions and maintain a patent airway. Restraints and oral airways can cause injury, while medication administration follows airway protection.