— 降低風險 · HARD · SATA —
護理師照護一位正處於癲癇發作的病人，下列哪些措施是正確的？（選所有適合的）
A nurse is caring for a client who is having a seizure. Which of the following actions should the nurse perform? (Select all that apply.)
- ALoosen clothing around the neck✓ 正解鬆開頸部的緊身衣物
- BPlace the client on their side✓ 正解將病人置於側臥位
- CInsert a padded tongue blade into the mouth將包裹軟墊的壓舌板插入口中
- DProtect the client's head from injury✓ 正解保護病人頭部免受傷害
- EAttempt to restrain the client's limbs嘗試約束病人四肢
— Explanation · 中文詳解 —
癲癇發作（Seizure）時的護理重點為「維護安全」與「保持呼吸道通暢」。護理師應移除周邊危險物品，保護頭部以免撞擊導致腦部二次傷害。將病人側臥（Recovery position）能防止嘔吐物誤吸，並維持呼吸道通暢。嚴禁在口中強塞異物，以免造成牙齒斷裂或阻塞氣道，也不應強行約束肢體，因為強力的肌肉收縮可能導致骨折。
During a seizure, the nurse prioritizes maintaining airway patency and preventing injury by loosening restrictive clothing and placing the client in a side-lying position to prevent aspiration. It is critical to protect the client’s head from trauma while avoiding the insertion of objects into the mouth or restraining the client, as these actions can cause dental damage, airway obstruction, or fractures.