— 降低風險 · EASY · SATA —
護理師照護一位有癲癇病史的病人，應採取哪些癲癇防護措施？（選所有適合的）
A nurse is caring for a client with a history of seizures. Which interventions should the nurse include in the client's seizure precautions? (Select all that apply.)
- AKeep a suction setup at the bedside✓ 正解在床邊備妥抽吸設備。
- BPlace a padded tongue blade at the bedside在床邊放置加襯墊的舌壓板。
- CPad the side rails of the bed✓ 正解為床欄加襯墊。
- DMaintain the bed in the lowest position✓ 正解保持病床處於最低位置。
- EEnsure the patient wears a medical alert bracelet確保病人佩戴醫療警示手環。
— Explanation · 中文詳解 —
癲癇防護措施的核心在於確保環境安全與呼吸道通暢。措施包括：在床邊準備抽吸設備（以防嘔吐物吸入）、床欄加軟墊（預防抽搐碰撞傷害）、將床位調低（防跌落）。現代護理指引已不建議在發作時使用口腔呼吸道（Oral airway）或舌壓板，因為痙攣時強行塞入會損傷牙齒並阻塞氣道。護理師應在發作時側臥病人，確保呼吸順暢。
Seizure precautions focus on maintaining a safe environment and ensuring airway patency by keeping suction equipment at the bedside, padding side rails, and keeping the bed in the lowest position. Modern guidelines advise against using tongue blades, as inserting objects into the mouth during a seizure can cause injury.