— 降低風險 · EASY · MCQ —
病人發生強直陣攣性癲癇發作，護理師在此期間應採取哪項措施？
A nurse is caring for a client who is having a tonic-clonic seizure. Which of the following actions should the nurse perform during the seizure?
- AAttempt to open the client's jaw嘗試打開客戶的下顎
- BRestrain the client's limbs to prevent injury約束客戶的四肢以預防受傷
- CInsert a padded tongue blade into the mouth將包紮過的舌壓板插入口中
- DTurn the client to the side✓ 正解將客戶轉為側臥
— Explanation · 中文詳解 —
癲癇發作時，首要安全原則是維持呼吸道通暢與預防受傷。側臥位（側向姿勢）可防止舌頭後倒阻塞呼吸道，並促使分泌物流出，避免吸入性肺炎。強迫開口或放置異物（C、A）會導致牙齒斷裂或軟組織受損。束縛肢體（B）會導致骨折。
Turning the client to the side is the priority action during a tonic-clonic seizure to maintain a patent airway and facilitate drainage of secretions, thereby preventing aspiration and respiratory compromise.
✦ 台美臨床差異
美台護理教育對於癲癇發作「不可放入異物」的原則皆已達成高度共識，過去舊式護理觀念在兩地皆已修正。