護理師照護癲癇發作的病人，護理師的優先事項為何？
A nurse is caring for a patient who is experiencing a seizure. What is the nurse's priority?
- AInserting an oral airway插入口腔通氣管
- BProtecting the client from injury✓ 正解保護病人免受傷害
- CRestraining the client's extremities約束病人的四肢
- DOpening the client's jaw with a tongue blade用壓舌板撬開病人的下巴
癲癇發作（Seizure）時，護理師的首要任務是確保病人的安全（Safety），即 ABC 原則中的安全環境維護。發作期間切勿強行約束肢體或將任何物體強行置入病人口中，因為這可能導致骨折、牙齒脫落或氣道阻塞。正確的做法是將病人側臥（Recovery position）以保持呼吸道通暢，並在頭部下方墊軟物防止撞擊。
During a seizure, the nurse's primary priority is to protect the client from physical injury, aligning with safety principles. It is crucial to avoid forcing an oral airway, restraining extremities, or inserting objects like tongue blades, as these actions can cause fractures, dental damage, or airway obstruction. Instead, the nurse should place the client in a side-lying position to maintain airway patency and pad the head to prevent trauma.
美國臨床更強調「側臥復甦姿勢（Side-lying recovery position）」以預防吸入性肺炎，且護理教育中極度強調「不准」在發作中放入任何東西到病人口中，這點與台灣教學一致，但美國實務上對此規範執行極為嚴格。