— 基本照護與舒適 · MEDIUM · SATA —
護理師為一位有癲癇病史的病人規劃照護計畫。下列哪些介入措施應包含在內？（選所有適合的）
A nurse is planning care for a client with a history of seizures. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- AKeep padded side rails up at all times✓ 正解隨時保持加墊床欄升起
- BMaintain suction equipment at the bedside✓ 正解在床邊備妥抽吸設備
- CPlace a tongue blade in the client's mouth if a seizure begins若癲癇發作開始，將壓舌板放入病人口中
- DEnsure the client has a patent intravenous access✓ 正解確保病人有暢通的靜脈通路
- ELoosen any clothing around the neck and chest✓ 正解鬆開頸部和胸部周圍的任何衣物
— Explanation · 中文詳解 —
癲癇發作照護重點在於保護病人免於受傷並確保呼吸道暢通。絕對禁止將任何物體（含壓舌板）放入發作中病人的口中，以免造成牙齒斷裂或呼吸道阻塞。床欄加墊、準備抽吸設備、保持靜脈通路給藥以及鬆開衣物以利呼吸，皆為標準安全防護措施。
Nursing care for a client with seizures focuses on maintaining a patent airway and preventing injury without placing objects in the mouth, which can cause trauma or aspiration. Interventions include keeping padded side rails up, having suction equipment ready, maintaining IV access for emergency medications, and loosening tight clothing around the neck to facilitate breathing.
✦ 台美臨床差異
美台對於癲癇防護原則一致，不過台灣對床欄使用常有約束力度的爭議，需謹慎評估。