— 安全與感染控制 · MEDIUM · MCQ —
護理師照顧一位有癲癇病史的病人。在癲癇發作時，護理師應優先確保什麼以保障安全？
A nurse is caring for a client with a history of seizures. What should the nurse prioritize to ensure safety during a seizure?
- AInsert a tongue blade into the client's mouth將壓舌板插入病人口中
- BClear the area of hard objects and protect the head✓ 正解清除區域內的硬物並保護頭部
- CForce medication into the client's mouth強行將藥物灌入病人口中
- DRestrain the client's arms to prevent injury約束病人的手臂以防止受傷
— Explanation · 中文詳解 —
對於有癲癇病史的病人，護理師應優先確保其在發作時的安全。核心護理措施為預防外傷（Injury prevention）。應即時移除周圍硬物、以枕頭保護頭部，絕對不可約束肢體（可能導致骨折），不可撬開牙關放置壓舌板（會導致牙齒斷裂或阻塞呼吸道），不可經口給藥。這些措施能最大程度地減少病人因抽搐而受到的二次傷害。
The priority during a seizure is preventing injury, so the nurse should clear the area of hard objects and protect the client's head. Inserting a tongue blade, forcing medication, or restraining the client can cause serious harm such as dental injury, aspiration, or fractures.