— 生理適應 · MEDIUM · SATA —
護理師照護一位有癲癇病史的病人。護理計畫應包含哪些措施？（選所有適合的）
A nurse is caring for a client with a history of seizures. What interventions should be included in the plan of care? (Select all that apply.)
- APad the side rails of the bed✓ 正解在床欄上鋪設軟墊
- BKeep a tongue blade at the bedside在床邊備置壓舌板
- CEnsure suction equipment is available✓ 正解確保抽吸設備可用
- DLoosen restrictive clothing around the neck✓ 正解鬆開頸部緊縮的衣物
- EPlace the client on their back during a seizure在癲癇發作期間讓病人仰臥
— Explanation · 中文詳解 —
癲癇護理重點在於保護安全。床欄加軟墊預防碰撞；抽吸設備備用預防吸入性肺炎；鬆開頸部衣物預防窒息。現代護理建議禁止使用壓舌板（易損壞牙齒）；發作時應採側臥位（Recovery position）防嘔吐窒息，而非平躺。
Safety is the priority for clients with seizures; padding side rails prevents injury from impact, loosening neck clothing ensures unobstructed airway, and having suction ready manages secretions. Tongue blades are contraindicated due to injury risk, and clients should be placed in a lateral position, not supine, to prevent aspiration.
✦ 台美臨床差異
台灣部分機構仍有放置壓舌板的習慣，但目前醫學教育已逐漸轉向禁止；美國則嚴格執行不放置物品原則。