— 基本照護與舒適 · HARD · MCQ —
發現病人發生癲癇發作時，護理師應優先採取哪項措施？
Which action should the nurse take first when discovering a client is having a seizure?
- AProtect the client from injury by clearing the area✓ 正解清除周圍區域以保護個案免受傷害
- BAdminister oxygen via face mask透過面罩給予氧氣
- CInsert a padded tongue blade into the mouth將包覆軟墊的壓舌板置入口中
- DRestrain the client's extremities約束個案的四肢
— Explanation · 中文詳解 —
癲癇發作首重安全防護（Safety）。清理周圍環境以防碰撞是第一優先。絕對不可強行將硬物放入病人口中（會導致牙齒斷裂或氣道阻塞），也不可強力束縛病人肢體（會導致骨折）。氧氣在發作後若有缺氧徵象才評估給予，並非第一步。
The first action during a seizure is to protect the client from injury by clearing the surrounding area of hazardous objects. Forcing items into the mouth or restraining the client can cause serious physical harm such as fractures or airway obstruction. Oxygen administration is not the initial priority during the active seizure phase.
✦ 台美臨床差異
美國護理指引嚴格禁止置入任何口內物，台灣教育亦同步，但臨床偶見老一輩醫護誤用。