— 生理適應 · HARD · MCQ —
病人正處於癲癇重積狀態 (Status epilepticus)。護理師的首要介入措施為何？
A client is experiencing status epilepticus. What is the nurse's priority intervention?
- AAdminister IV Lorazepam靜脈注射勞拉西泮
- BApply oxygen via non-rebreather mask透過非再呼吸面罩給予氧氣
- CPlace the client in a side-lying position✓ 正解將個案置於側臥姿勢
- DInsert an oral airway插入口腔通氣管
— Explanation · 中文詳解 —
癲癇發作時，首要護理目標是保護病人安全與維持呼吸道通暢。將病人轉向側面 (Side-lying position) 可防止舌頭後墜阻塞呼吸道，並減少吸入性肺炎的風險。D 選項不可強行放置口咽通氣道，易造成牙齒斷裂；A 選項雖重要，但在確保病人未受傷前，姿勢調整為最急迫之護理措施。
Placing the client in a side-lying position is the priority nursing intervention to maintain airway patency by preventing tongue obstruction and reducing the risk of aspiration. This immediate action ensures safety before administering medications or other interventions.
✦ 台美臨床差異
美台臨床皆將保護病人安全列為癲癇護理首要，兩者皆強烈禁止於發作時強行撬開牙關。