— 安全與感染控制 · MEDIUM · SATA —
護理師照顧癲癇病史病人，應執行哪些介入措施以確保安全？（選所有適合的）
A nurse is caring for a client with a history of seizures. Which interventions should the nurse perform to ensure safety? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將床置於最低位置
- BMaintain side rails in the up position and padded✓ 正解保持床欄升起並加裝護墊
- CKeep suction equipment and oxygen at the bedside✓ 正解在床邊備妥抽吸設備與氧氣
- DInsert a padded tongue blade during a seizure在發作期間插入加護壓舌板
- EPlace a pillow under the client's head during a seizure✓ 正解在發作期間於病人頭下墊枕頭
— Explanation · 中文詳解 —
癲癇發作（seizure）的護理核心是「安全第一」與「維持呼吸道通暢」。護理師應預防病人跌倒、頭部撞擊及誤吸（aspiration）。在發作過程中，絕對禁止強行將任何物品（如舌板）塞入病人口中，以免導致牙齒斷裂或口腔組織撕裂。正確措施包括保持低床位、床欄加護墊防碰撞，以及準備好抽吸設備，以防發作後出現嘔吐造成窒息。
To ensure safety for a client with a history of seizures, keep the bed in the lowest position and maintain padded side rails to prevent injury from falls or collisions. Suction equipment and oxygen should be kept at the bedside to manage airway patency post-ictally. Never insert objects into the client's mouth during a seizure, as this can cause oral trauma; instead, place a pillow under the head to protect it from hard surfaces.