— 降低風險 · MEDIUM · SATA —
護理師照護一位有癲癇病史的病人，在強直陣攣發作（Tonic-Clonic Seizure）期間，應採取哪些措施？（選所有適合的）
A nurse is caring for a client with a history of seizures. Which actions should the nurse take during a tonic-clonic seizure? (Select all that apply.)
- AInsert a padded tongue blade into the mouth將包有軟墊的壓舌板置入口中
- BTurn the client to the side✓ 正解將病人轉為側臥
- CLoosen restrictive clothing✓ 正解鬆開束縛性衣物
- DProtect the head from injury✓ 正解保護頭部免受傷害
- EAttempt to restrain the client's extremities嘗試約束病人的四肢
— Explanation · 中文詳解 —
強直陣攣發作（Tonic-Clonic Seizure）的護理核心在於「保護安全」與「維持呼吸道」。發作時病人意識喪失且肌肉強直與陣攣，此時應採取側臥位（Recovery position）以防嘔吐物吸入導致窒息，並移除周圍危險物品或鬆開緊身衣物（特別是頸部）以利呼吸。保護頭部是為了防止反覆撞擊造成腦部創傷。嚴禁強行約束或放入異物，這些行為極易引發骨折、牙齒斷裂或軟組織損傷，甚至造成護理師自身受傷。
The client's statement indicates a loss of hope and potential suicidal ideation, making the presence of a plan or intent for self-harm the highest priority assessment. Ensuring immediate physical safety takes precedence over evaluating nutritional intake, ADL capabilities, or family support systems.