— 生理適應 · EASY · SATA —
護理師照護一位癲癇發作的病患，應採取哪些措施？（選所有適合的）
A nurse is caring for a client experiencing a seizure. Which interventions should the nurse perform? (Select all that apply.)
- ATurn the client to their side✓ 正解將個案轉為側臥
- BPlace a padded tongue blade in the client's mouth在個案口中放入包覆軟墊的壓舌板
- CClear the area of hard objects✓ 正解清除周圍的硬物
- DTime the duration of the seizure✓ 正解記錄發作持續時間
- ELoosen restrictive clothing✓ 正解鬆開限制性衣物
— Explanation · 中文詳解 —
癲癇發作時的護理重點在於保護病患安全。側臥位有助於呼吸道通暢並防止誤吸；移除周遭尖銳物可預防挫傷；記錄發作時間以供醫療評估；解開束縛物以利擴胸。絕對嚴禁放入任何物品進口中，以免造成牙齒斷裂或呼吸道阻塞。
During a seizure, the nurse should turn the client to their side to maintain airway patency and prevent aspiration of secretions. It is essential to clear the area of hard or sharp objects to prevent physical injury and to loosen restrictive clothing to facilitate breathing. The nurse must time the seizure duration to guide medical management. Inserting objects into the mouth is strictly contraindicated as it can cause dental damage or airway obstruction.
✦ 台美臨床差異
兩地皆遵循國際癲癇急救原則，強調絕對不可強行撬開牙關放入物品。