— 降低風險 · MEDIUM · SATA —
護理師照護一位有癲癇病史的病人，哪些介入能降低發作時的受傷風險？（選所有適合的）
A nurse is caring for a client with a history of seizures. Which interventions decrease the risk of injury during a seizure? (Select all that apply.)
- AProtect the head by placing a pillow underneath✓ 正解在頭部下方放置枕頭加以保護
- BLoosen clothing around the neck✓ 正解鬆開頸部的衣物
- CTurn the client to their side✓ 正解將病人轉為側臥
- DHold the client's extremities firmly用力固定病人的四肢
- EInsert a soft cushion in the mouth在口中插入軟墊
— Explanation · 中文詳解 —
癲癇（Seizure）發作時的護理重點在於「保護病人安全」與「維持呼吸道通暢」。護理師應立即將病人移至平坦地面或床鋪，移除周圍危險家具，並採取側臥姿勢以防嘔吐物吸入（Aspiration）。絕對禁止在病人發作時強行束縛其肢體，這極易導致骨折或肌肉韌帶損傷，亦嚴禁強行塞入異物進口腔，以免造成呼吸道阻塞。
During a seizure, the nurse should protect the client’s head with a pillow, loosen tight clothing around the neck, and turn the client to the side to maintain airway patency and prevent aspiration. Restraining the client or inserting objects into the mouth is contraindicated as it increases the risk of injury and airway obstruction.