— 安全與感染控制 · MEDIUM · SATA —
護理師照顧一位有癲癇病史的病人，哪些措施有助於安全？（選所有適合的）
A nurse is caring for a client with a history of seizures. Which interventions are appropriate for safety? (Select all that apply.)
- AKeep the side rails up and padded✓ 正解保持床欄拉起並加裝軟墊
- BInsert a tongue blade during the seizure在抽搐期間插入壓舌板
- CClear the area of hard objects✓ 正解清除周圍的硬物
- DTurn the client to their side during the seizure✓ 正解在抽搐期間將病人轉為側臥
- ELoosen any restrictive clothing✓ 正解鬆開任何限制性衣物
— Explanation · 中文詳解 —
癲癇（Seizure）發作時的護理重點在於「保護病人免受傷害」。常見措施包括：確保床欄升起並加裝軟墊（防止撞擊）、發作時將病人側臥（防止嘔吐物吸入）、移除周遭硬物、鬆開緊身衣物以利呼吸。絕對禁止在發作時向病人口中強行放置任何物品（如壓舌板），這極易導致牙齒斷裂或呼吸道阻塞，是 NCLEX 常考的錯誤行為。
Safety measures include raising padded side rails, clearing hard objects, turning the client to the side to prevent aspiration, and loosening restrictive clothing. Placing objects in the mouth is strictly prohibited due to the risk of dental injury and airway obstruction.