— 安全與感染控制 · HARD · SATA —
患有陣攣性大發作癲癇的病人出現哪些徵象需立即介入？（選所有適合的）
Which assessment findings indicate a need for immediate intervention in a client with a history of tonic-clonic seizures? (Select all that apply.)
- AThe client is observed clenching teeth during a seizure觀察到病人在發作期間緊咬牙齒
- BThe client becomes apneic during a seizure✓ 正解病人在發作期間出現呼吸暫停
- CThe client attempts to climb out of bed during the post-ictal phase✓ 正解病人在發作後期試圖爬出床鋪
- DThe client develops cyanosis during a seizure✓ 正解病人在發作期間出現發紺
- EThe client has a period of confusion after the seizure病人在發作後有一段時間的意識混亂
— Explanation · 中文詳解 —
癲癇發作時的優先護理重點在於呼吸道安全與預防受傷。陣攣性大發作（Tonic-clonic seizure）可能導致呼吸暫停與缺氧，必須嚴密監測呼吸徵象。發作後的發作後期（Post-ictal phase）病人意識模糊，極易發生跌倒，需加強保護措施。護理師需區分發作時的正常表現與危險徵象，並即時介入以避免併發症。
Immediate intervention is required for apnea and cyanosis, as these indicate airway compromise and severe hypoxia during a seizure. Additionally, the client requires protection from falls due to post-ictal confusion, which poses a significant safety risk. While tooth clenching and post-ictal confusion are expected findings, respiratory distress and injury risk demand urgent action.