— 生理適應 · EASY · MCQ —
下列哪項護理措施適合用於正在經歷強直陣攣性癲癇發作的病人？
Which of the following nursing interventions is appropriate for a patient experiencing a tonic-clonic seizure?
- ATurn the patient to their side✓ 正解將病人轉為側臥
- BAttempt to insert an oral airway嘗試置入口腔氣道
- CRestrain the patient's limbs to prevent injury約束病人肢體以預防受傷
- DPlace a padded tongue blade in the patient's mouth在病人口中放置加墊的壓舌板
— Explanation · 中文詳解 —
強直陣攣性癲癇（Tonic-clonic seizure）發作時，護理的核心目標是「保護安全」與「維持氣道暢通」。將病人轉為側臥位（Side-lying position）是為了防止嘔吐物吸入呼吸道，並讓舌頭因重力自然偏向一側，避免阻塞氣道。絕對不可強行撬開牙關或放入異物，以免造成病人牙齒斷裂或口腔黏膜損傷。
Turning the patient to their side promotes airway clearance and prevents aspiration of secretions or vomitus. This position allows the tongue to fall forward, maintaining a patent airway during the seizure. Other interventions like restraint or inserting objects into the mouth can cause injury and are contraindicated.