— 照護管理 · MEDIUM · SATA —
護理師負責照顧一位有癲癇病史的病人。應採取哪些措施以確保安全？（選所有適合的）
A nurse is managing the care of a client with a history of seizures. Which actions should the nurse take to ensure safety? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將床置於最低位置
- BMaintain suction equipment at the bedside✓ 正解在床邊備妥抽吸設備
- CEnsure padded side rails are in place✓ 正解確保已放置軟墊床欄
- DPlace a padded tongue blade at the bedside在床邊放置軟質壓舌板
- EApply soft wrist restraints to prevent injury during a seizure施加軟質手腕約束帶以防止發作時受傷
— Explanation · 中文詳解 —
癲癇安全照護準則包含：低床位防止跌倒、備妥抽吸設備以防口腔分泌物引發吸入性肺炎、設置軟墊床欄防止碰撞受傷。D 選項：現代護理已不建議使用壓舌板，以免造成口腔組織損傷或斷裂造成氣道異物。E 選項：約束會限制病人活動，反而增加癲癇發作時的肌肉拉傷風險，絕對不可使用。
Safety measures for clients with seizures include keeping the bed in the lowest position to prevent fall injuries, placing padded side rails to protect against impact, and keeping suction equipment available to manage secretions. Tongue blades and restraints are contraindicated as they pose risks of oral trauma and increased physical injury.
✦ 台美臨床差異
美國醫院全面禁用壓舌板，台灣臨床亦逐漸採此準則，但老一代護理師可能仍留有舊習慣。