— 降低風險 · MEDIUM · SATA —
護理師規劃一位有癲癇病史病人的護理措施。哪些應納入護理計畫？（選所有適合的）
A nurse is assisting a client with a history of seizures. Which of the following should the nurse incorporate into the plan of care? (Select all that apply.)
- AKeep a tongue blade at the bedside在床邊備妥壓舌板
- BMaintain a patent airway✓ 正解維持呼吸道暢通
- CPad the side rails✓ 正解加墊床欄
- DPlace the client in a side-lying position✓ 正解將病人置於側臥姿勢
- ERestrict all physical activity限制所有身體活動
— Explanation · 中文詳解 —
癲癇發作時的護理優先順序為維持呼吸道通暢（Airway）與預防物理性傷害（Safety）。將病人側臥可防止舌頭後墜阻塞呼吸道，並讓口腔分泌物排出。床欄加墊可防止強直陣攣發作時碰撞受傷。現代護理準則嚴禁在發作時將壓舌板放入病人口中，因為這極易導致牙齒斷裂、軟組織受傷，甚至造成吸入性窒息。護理重點應在於發作中的保護與發作後的觀察。
Maintaining a patent airway is the priority during a seizure to ensure adequate oxygenation. Placing the client in a side-lying position facilitates the drainage of secretions and reduces the risk of aspiration. Padding the side rails helps prevent physical injury from striking hard surfaces during convulsive movements. Using a tongue blade is contraindicated as it can cause dental damage or airway obstruction.