護理師督導一位協助照護癲癇病史病人的護理助理（UAP）。下列何種觀察需要護理師立即介入？
A nurse is supervising an unlicensed assistive personnel (UAP) who is providing care for a client with a history of seizures. Which observation requires immediate intervention by the nurse?
- AThe UAP assists the client with personal hygiene護理助理協助病人進行個人衛生
- BThe UAP ensures the side rails are padded護理助理確保床欄已加墊
- CThe UAP reports the client is complaining of a headache護理助理回報病人抱怨頭痛
- DThe UAP places a padded tongue blade at the bedside✓ 正解護理助理將加墊壓舌板放置在床邊
癲癇發作時的護理核心在於「維護安全」與「防止損傷」。現代實證護理準則已明確禁止在發作期間將任何物體（如壓舌板）放入病人口中，因為這極易導致牙齒斷裂、口腔黏膜撕裂，甚至因異物脫落造成呼吸道阻塞。護理師應確保床邊設有抽吸與氧氣設備，並在發作時移除危險物品，保護頭部，而非採取侵入性措施。監督 UAP 時，若發現其執行了可能損害病人安全的行為，護理師必須立即介入以防止不良後果。
The nurse must intervene immediately if the UAP places a tongue blade at the bedside, as current evidence-based guidelines strictly prohibit inserting any objects into a seizing client's mouth due to the high risk of dental fracture and airway obstruction. Safety measures should instead focus on protecting the head and ensuring suction equipment is available.
台美臨床對於癲癇發作的「禁止放置異物」觀念一致。但在美國，UAP（如 CNA）的職責範圍（Scope of Practice）更為嚴格，護理師對 UAP 的監督責任（Delegation & Supervision）在 NCLEX 中是重點，護理師需確保 UAP 不會執行超出其權限或不安全的行為。