— 照護管理 · MEDIUM · SATA —
護理師應採取哪些措施以確保癲癇發作時的病人安全？（選所有適合的）
Which of the following interventions should a nurse implement to ensure client safety during a seizure? (Select all that apply.)
- ALoosen any restrictive clothing around the client's neck✓ 正解鬆開病人頸部周圍的任何束縛衣物
- BPlace a pillow under the client's head✓ 正解在病人頭下放置枕頭
- CInsert an oral airway to prevent tongue biting插入口腔導管以防止咬舌
- DTurn the client to their side to prevent aspiration✓ 正解將病人轉為側臥以防止吸入
- ETime the duration of the seizure✓ 正解記錄發作的持續時間
— Explanation · 中文詳解 —
癲癇發作（Seizure）時的護理核心在於「保護」與「維持呼吸道通暢」。NCLEX 極度強調安全（Safety），護理師需保護病人頭部免受撞擊，移除可能造成勒頸或傷害的物品，並在發作後採取側臥姿勢以防止嘔吐物吸入（Aspiration）。嚴禁強行張開病人口腔或放入任何物品，以免導致牙齒斷裂或氣道阻塞。
During a seizure, the nurse must prioritize airway patency and physical safety by loosening restrictive clothing and cushioning the head to prevent injury. Turning the client to the side facilitates drainage of secretions to prevent aspiration, while timing the seizure assists in diagnostic evaluation. Inserting oral airways is contraindicated as it poses a high risk of trauma and airway obstruction.