— 安全與感染控制 · EASY · MCQ —
病人發生強直陣攣性癲癇發作時，護理師優先採取的行動為何？
Which action should the nurse take first when a client is experiencing a tonic-clonic seizure?
- AInserting a tongue blade to prevent tongue biting插入壓舌板以防止咬傷舌頭
- BRestraining the client's limbs to prevent injury約束病人的四肢以防止受傷
- CProtecting the client's head from injury✓ 正解保護病人的頭部免受傷害
- DAdministering oral medication to stop the seizure給予口服藥物以停止癲癇發作
— Explanation · 中文詳解 —
癲癇發作時，護理師的首要目標是「保護病人免受物理傷害」。強直陣攣性癲癇（Tonic-clonic seizure）發作時，病人會失去意識且肢體劇烈抽動，極易撞擊周遭環境導致外傷。護理師應將病人側臥，清除周遭危險物品，並以枕頭或手部保護頭部。切記不可強行約束肢體，也不可將任何物體（如壓舌板）放入病人口中，以免造成牙齒斷裂或阻塞呼吸道。
The first action during a tonic-clonic seizure is to protect the client from physical harm, as loss of consciousness and violent muscle contractions pose significant injury risks. The nurse should clear the area of dangerous objects, turn the client to the side to maintain airway patency, and cushion the head. Restraining limbs or inserting oral devices is contraindicated as it can cause fractures or airway blockage.