— 基本照護與舒適 · MEDIUM · SATA —
護理師在病人癲癇發作時，下列哪些措施有助於維護其安全？（選所有適合的）
Which actions by the nurse help to maintain client safety during a seizure? (Select all that apply.)
- AClear the area of hard objects✓ 正解清除區域內的硬物
- BPlace a padded tongue blade in the mouth將包紮過的壓舌板放入口中
- CTurn the client to the side✓ 正解將病人轉為側臥
- DRestrain the client's extremities to prevent injury約束病人四肢以預防受傷
- ELoosen clothing around the neck✓ 正解鬆開頸部的衣物
— Explanation · 中文詳解 —
癲癇發作護理以「保護頭部、確保呼吸道」為原則。移開硬物可防撞傷，側臥可防止呼吸道阻塞或吸入性肺炎，鬆開領口則是為了維持呼吸順暢。放入舌板（B）易導致牙齒斷裂或吸入異物；約束肢體（D）則可能因過度用力造成骨折。
To ensure client safety during a seizure, the nurse should clear the area of hard objects to prevent trauma, turn the client to the side to facilitate drainage and prevent aspiration, and loosen tight clothing around the neck to maintain a patent airway. Inserting objects into the mouth or restraining the client is contraindicated as it risks dental injury, aspiration, or fracture.
✦ 台美臨床差異
台美皆已更新指引禁止使用舌板，護理教育皆強調側臥與環境淨空。