— 安全與感染控制 · MEDIUM · SATA —
護理師照護一位有癲癇病史的病人，大發作時應優先採取哪些安全措施？（選所有適合的）
A nurse is assisting a client with a history of seizure disorders. Which safety measures should be prioritized during a grand mal seizure? (Select all that apply.)
- ATurn the client to their side✓ 正解將病人轉向側臥
- BPlace a padded tongue blade in the mouth在口中放置包墊的壓舌板
- CLoosen restrictive clothing✓ 正解鬆開限制性衣物
- DRemove glasses and objects around the head✓ 正解移除眼鏡及頭部周圍的物體
- ERestrain the client's limbs to prevent injury約束病人四肢以防止受傷
— Explanation · 中文詳解 —
癲癇發作時的處理重點是保護病人免受二次外傷。側臥（A）可維持呼吸道通暢，解開束縛衣物（C）避免阻礙呼吸，移除頭部周遭危險物（D）可防止碰撞。放置舌板（B）易損傷牙齒與口腔，約束肢體（E）則會增加骨折機率，均為錯誤處置。
During a grand mal seizure, the priority is preventing aspiration and injury by turning the client to their side, loosening restrictive clothing to facilitate breathing, and removing nearby objects to protect the head. Placing objects in the mouth or restraining limbs is contraindicated as it increases the risk of dental injury, fractures, or airway obstruction.
✦ 台美臨床差異
台美現代護理學教育皆已修正禁止強塞異物入癲癇病人嘴中，臨床觀念已趨於一致。