— 安全與感染控制 · MEDIUM · MCQ —
病人正經歷強直陣攣性癲癇發作，護理師應立即採取哪項行動？
A client is experiencing a tonic-clonic seizure. Which action should the nurse take immediately?
- AInsert an oropharyngeal airway置入口咽通氣管
- BRestrain the client's limbs約束病人四肢
- CTurn the client to the side✓ 正解將病人轉為側臥
- DPlace a padded tongue blade in the client's mouth在病人口中放入加墊的壓舌板
— Explanation · 中文詳解 —
癲癇發作（Seizure）時，護理師的優先目標是維護病人呼吸道通暢與防止外傷。強直陣攣發作時，病人會出現強烈肢體抽動，此時應讓病人側臥（Recovery position）以利口水或嘔吐物排出，防止吸入性肺炎。切勿強行約束肢體，以免造成骨折或肌肉損傷。嚴禁在病人發作時往口中放入任何異物（如壓舌板），因為病人的咬合力極強，容易導致牙齒斷裂掉入氣道，造成窒息。
During a tonic-clonic seizure, the nurse's priority is to maintain a patent airway and prevent injury by turning the client to the side. This position facilitates drainage of secretions and reduces the risk of aspiration. Inserting objects into the mouth or restraining the client is dangerous and can cause dental damage, fractures, or muscle strain.