— 生理適應 · EASY · SATA —
護理師照顧一位有癲癇病史的病人。護理計畫中應包含哪些措施來預防受傷？（選所有適合的）
A nurse is caring for a client with a history of seizures. Which interventions should the nurse include in the plan of care to prevent injury? (Select all that apply.)
- APadding the side rails of the bed✓ 正解在床欄上加裝保護墊
- BKeeping a suction setup available at the bedside✓ 正解在床邊備妥抽吸設備
- CPlacing a bite block in the mouth during a seizure在發作期間將咬合板置入口中
- DKeeping the bed in the lowest position✓ 正解將床置於最低位置
- ERemoving restrictive clothing✓ 正解移除限制性衣物
— Explanation · 中文詳解 —
癲癇發作時的護理核心在於環境安全與預防受傷。護理師需預先建立安全環境，包含床欄加墊以防止抽搐時肢體碰撞受傷、保持床位最低位置以預防跌落。抽吸設備是為了在發作後若病人有嘔吐或分泌物過多時，能維持呼吸道通暢。解開緊身衣物有助於胸廓擴張，改善呼吸。絕不可嘗試在發作時往病人口中放置任何物體，這是嚴重的錯誤處置，會導致牙齒脫落、口腔組織撕裂或阻塞氣道。
To prevent injury during a seizure, the nurse should pad side rails, keep the bed in the lowest position, remove restrictive clothing, and have suction equipment available for airway management. Placing objects in the mouth is contraindicated as it risks oral trauma and airway obstruction, whereas environmental safety measures protect the client from physical harm.