一位有癲癇病史的患者，在發生強直陣攣性發作後，護理師應記錄哪些觀察發現？（選所有適合的）
A nurse is caring for a client with a history of seizures. Which assessment findings should the nurse document after a tonic-clonic seizure? (Select all that apply.)
- AThe duration of the seizure✓ 正解發作持續的時間
- BThe client's level of consciousness after the event✓ 正解事件發生後病人的意識程度
- CPresence of tongue biting or incontinence✓ 正解是否有舌咬傷或大小便失禁
- DThe medication administered to abort the seizure用於中止發作所給予之藥物
- EThe specific aura experienced before the seizure✓ 正解發作前經歷之特定先兆
詳細記錄癲癇發作前後過程對醫師評估治療效果極重要。發作時間（Duration）攸關狀態癲癇（Status Epilepticus）的預防；意識狀態（LOC）反映恢復情況；舌咬或失禁顯示發作嚴重度；前驅症狀（Aura）提供癲癇起源的線索。D選項為處置記錄，非屬發作當下的生理評估發現。
Accurate documentation of seizure details is vital for evaluating treatment efficacy and identifying complications such as status epilepticus. Key assessments include the duration of the seizure, the client's post-ictal level of consciousness, signs of trauma like tongue biting or incontinence, and any preceding aura, which helps localize the seizure onset. Recording administered medications is an intervention note rather than a direct assessment of the seizure event itself.
美台護理評估癲癇的準則一致，但在台灣，護理師常需更詳細描述發作當時的肢體抽動模式（如左右側差異），以協助醫師判斷病灶側。