— 基本照護與舒適 · MEDIUM · SATA —
護理師照護一位有癲癇病史的病人。護理計畫應包含哪些護理措施？（選所有適合的）
A nurse is caring for a client with a history of seizures. Which interventions should be included in the client's care plan? (Select all that apply.)
- APad the side rails of the bed✓ 正解在床欄上加裝保護墊
- BKeep a tongue blade at the bedside at all times床邊常備壓舌板
- CMaintain suction equipment at the bedside✓ 正解在床邊備妥抽吸設備
- DEnsure oxygen setup is functional✓ 正解確保氧氣供應設備功能正常
- EPlace the client on NPO status permanently永久將病人列為禁食 (NPO)
— Explanation · 中文詳解 —
預防癲癇發作時受傷，應預先進行環境安全準備：床欄加軟墊防止撞傷、備妥抽吸設備以利清除分泌物、氧氣設備以備發作後缺氧。嚴禁強行放置壓舌板（易導致呼吸道阻塞或牙齒斷裂）。NPO 僅在急性發作期，非長期措施。
Care plans for clients with seizures should prioritize safety by padding side rails to prevent injury and ensuring suction and oxygen equipment are available to manage airway patency and post-ictal hypoxia. Placing objects like tongue blades in the mouth is contraindicated due to the risk of airway obstruction or dental injury.
✦ 台美臨床差異
美台臨床皆嚴禁壓舌板使用；台灣病房常配有防咬軟墊，與美國床欄軟墊概念一致。