— 降低風險 · MEDIUM · MCQ —
護理師照護一位正處於大發作癲癇的病人。護理師首要行動是什麼？
A nurse is caring for a client who is having a grand mal seizure. What is the priority nursing action?
- AProtect the client's head from hitting hard surfaces✓ 正解保護病人頭部以免撞擊硬物表面
- BAttempt to stop the seizure with medication嘗試用藥物制止癲癇發作
- CInsert an oral airway插入口腔通氣管
- DRestrain the client's limbs to prevent injury約束病人四肢以防止受傷
— Explanation · 中文詳解 —
大發作癲癇（Grand mal seizure）的護理優先級遵循安全原則（Safety）。首要任務是保護病人免受物理傷害，特別是頭部。絕對不可約束肢體，以免造成骨折或脫臼，更不可強行放入口腔器具（如壓舌板），以免造成牙齒斷裂或阻塞呼吸道。隨後應側臥（Recovery position）以維持呼吸道通暢。
The priority nursing action during a grand mal seizure is to protect the client’s head from injury by cushioning it, as preventing physical harm is paramount. Nurses must never restrain the client’s limbs or insert objects into the mouth, as these actions can cause fractures, dislocations, or airway obstruction.