— 降低風險 · MEDIUM · SATA —
護理師照護一位有癲癇病史的病人。下列哪些護理措施應納入照護計畫以確保病人安全？（複選題）
A nurse is caring for a client with a history of seizures. Which interventions should the nurse include in the plan of care to ensure patient safety? (Select all that apply.)
- AKeep suction equipment at the bedside✓ 正解在病床邊備妥抽吸設備
- BKeep side rails up and padded✓ 正解拉起床欄並加墊保護
- CPlace a padded tongue blade at the bedside在病床邊放置加墊的壓舌板
- DLoosen restrictive clothing around the neck✓ 正解鬆開頸部緊束的衣物
- EClear the area of hard objects during a seizure✓ 正解在發作期間清除周圍的硬物
— Explanation · 中文詳解 —
癲癇發作的防護重點為維持呼吸道暢通與預防外傷。放置抽吸設備以備發作後清除分泌物；柵欄加墊可防碰撞；鬆開領口促進呼吸；移開硬物預防腦震盪。注意：現代護理標準已不建議在發作時強行放入舌壓板，以免造成口腔損傷。
Ensuring patient safety during seizures involves maintaining airway patency with suction equipment, padding side rails to prevent injury, loosening restrictive neck clothing, and clearing the area of hard objects. Placing a tongue blade is no longer recommended as it poses a risk of oral trauma. These interventions focus on protecting the client from physical harm while facilitating breathing post-seizure.
✦ 台美臨床差異
台灣部分資深人員仍有放置壓舌板習慣，但目前醫學中心皆已全面改為臨床指引所建議的『不放置』原則。