護理師正在照護一位有全身性強直陣攣性發作病史的病人。應實施哪項安全措施？
The nurse is caring for a client with a history of generalized tonic-clonic seizures. Which safety measure should the nurse implement?
- AKeep a tongue blade at the bedside to prevent tongue biting在床邊備妥壓舌板以防止咬傷舌頭
- BRestrain the client's limbs to prevent injury during activity約束病人的肢體以預防活動時的傷害
- CMaintain the side rails in the up position with padding✓ 正解保持床欄拉起並加墊
- DPlace the client in a supine position during a seizure在發作期間將病人置於仰臥位
癲癇安全防護的核心在於預防受傷與維持呼吸道通暢。加墊的床欄（padded side rails）能防止病人在強烈抽搐時撞擊堅硬的床架造成骨折或瘀青，是標準的癲癇預防措施。護理思路應優先考慮環境安全（Safety first）。選項 A 是錯誤的古老觀念，將物品塞入病人嘴巴會造成牙齒損傷或呼吸道阻塞；選項 D 錯誤，發作時應採側臥位（lateral position）以防止嘔吐物造成吸入性肺炎；選項 B 錯誤，限制病人的肢體活動反而會導致肌肉拉傷或骨折，應讓病人自由抽動，僅需移除周邊危險物品。
Safety measures for a client with seizures prioritize preventing injury and maintaining airway patency without restraint. The nurse should keep padded side rails up to protect against falls during convulsions, avoid inserting objects into the mouth to prevent trauma, and position the client on their side to prevent aspiration, rather than restraining limbs or keeping them supine.
美國 NCLEX 指引強調床欄加墊是癲癇防護（Seizure Precautions）的必備環節；台灣部分醫院雖有此概念，但未必每間病房都備有專用的床欄墊，有時會以枕頭或棉被暫時代替，且台灣護理紀錄較強調發作時間與型態的詳盡描述。