護理師在病人癲癇發作時，應採取哪些措施以維護安全？（選所有適合的）
Which actions should the nurse perform to maintain client safety during a seizure? (Select all that apply.)
- APlace the client on their side✓ 正解將病人置於側臥位
- BInsert a padded tongue blade插入加護壓舌板
- CClear the area of hard objects✓ 正解清除區域內的硬物
- DRestrain the client's extremities約束病人的四肢
- ELoosen clothing around the neck✓ 正解鬆開頸部的緊身衣物
癲癇（Seizure）發作時的護理核心在於「保護病人免受物理傷害」及「維持呼吸道通暢」。護理師應保持冷靜，記錄發作時間與特徵。側臥位（Side-lying position）能利用重力使舌頭下垂，防止舌頭後縮阻塞呼吸道，並讓口腔分泌物順利流出，降低吸入性肺炎風險。移除周遭尖銳物品能防止病人因抽搐撞傷，而鬆開頸部衣物則可避免壓迫頸部靜脈或呼吸道，確保呼吸不受限。
During a seizure, place the client on their side to facilitate drainage of secretions and prevent aspiration. Clear the area of hard objects to minimize the risk of injury from thrashing movements. Loosen clothing around the neck to ensure adequate airway clearance. Do not insert a tongue blade or restrain the client's extremities, as these actions can cause significant physical trauma.
在美國臨床護理中，強調「絕對不可（Never）」放入任何東西到病人口中是考題核心。台灣臨床偶見老一輩醫護仍有使用壓舌板的習慣，但在 NCLEX 考試中，這被視為錯誤且危險的護理處置。