護理師發現病人正發生全身性強直陣攣性癲癇發作。護理師應首先採取哪項安全措施？
The nurse identifies that a client is experiencing a generalized tonic-clonic seizure. Which safety action should the nurse take first?
- AInsert a padded tongue blade into the client's mouth.將加襯墊的壓舌板插入病人口中
- BRestrain the client's limbs to prevent injury.約束病人四肢以預防受傷
- CAdminister oxygen via a simple face mask.透過簡單面罩給予氧氣
- DTurn the client to the side-lying position.✓ 正解將病人轉為側臥姿勢
癲癇發作時的護理首要任務是維護『氣道通暢』與『預防受傷』。轉向側臥位（D）是保護呼吸道的關鍵動作，能防止唾液或嘔吐物阻塞氣道或導致吸入性肺炎。選項 A（置入壓舌板）是絕對禁止的錯誤行為，這可能導致牙齒斷裂或舌頭受傷，甚至阻塞氣道。選項 B（約束肢體）也是錯誤的，癲癇發作時強行按壓肢體可能導致骨折或肌肉損傷，應移除周邊危險物品而非限制病人。選項 C（給氧）雖然重要，但在確保氣道未被分泌物阻塞前，給氧效果有限。護理師應維持冷靜，計時並觀察發作形態，待發作結束後再進行深度評估。
The priority nursing action during a generalized tonic-clonic seizure is to maintain a patent airway by turning the client to a side-lying position, which facilitates drainage of secretions and prevents aspiration. Placing objects in the mouth or restraining the client is contraindicated as it increases the risk of injury and airway obstruction.
在美國護理教學中，『Nothing in the mouth』是極其強調的安全教條。台灣某些舊觀念仍可能認為要塞毛巾防咬舌，這是錯誤且危險的。此外，美國醫院多會將病床護欄包裹軟墊（Seizure pads）作為高風險病人的標準預防，台灣則視各院設備而定。