一位22歲患有癲癇病史的男性因嚴重腸胃炎及無法吸收口服抗癲癇藥物入院。他的血清鈉離子為 125 mEq/L。認知到即將引發全身僵直陣攣性發作的極高風險，護理師必須執行哪些環境與安全的防護措施？（多選題）
A 22-year-old male with a history of epilepsy is admitted with severe gastroenteritis and an inability to retain oral anti-seizure medications. His serum sodium is 125 mEq/L. Recognizing the exceptionally high risk for an imminent tonic-clonic seizure, which environmental and safety precautions must the nurse implement? (Select all that apply.)
- AEnsure oxygen delivery equipment and a functioning suction apparatus are set up and available at the bedside.✓ 正解確保氧氣給送設備及功能正常的抽吸裝置已設置並置於床邊。
- BPlace a rigid padded tongue blade at the head of the bed to insert into the airway at the onset of a seizure.在床頭放置硬質襯墊舌壓板，以便在發作開始時插入氣道。
- CPad the side rails of the bed and ensure the bed is locked in its lowest possible position.✓ 正解包覆床側欄護墊，並確保病床鎖定於最低位置。
- DRestrain the patient's arms and legs loosely using soft ties to prevent thrashing injuries during convulsions.使用軟質束帶鬆散地約束病人的四肢，以防止抽搐期間受傷。
- EInstruct the patient to unbutton tight clothing around the neck before sleeping.✓ 正解指示病人在睡前解開頸部緊身衣物的鈕扣。
本題測驗癲癇防護常規（Seizure Precautions）。當病患有極高機率發生大發作時（如本題低鈉血症與停藥），防護焦點在於「防止窒息與撞擊」。床頭必須準備好立即能用的壁式氧氣與抽痰設備，以清除發作後產生的豐富口水或嘔吐物（選項A正確）。將所有床欄包覆護墊，且將病床降至最低，能防止跌落及四肢撞擊金屬邊緣受傷（選項C正確）。解開頸部周圍過緊的衣物可避免呼吸道受阻與勒頸風險（選項E正確）。然而，在癲癇抽搐期間，用任何外力固定與束縛病患抽動的四肢（如綁帶約束）會直接導致嚴重的關節脫臼與肌肉撕裂傷（選項D禁忌錯誤）。此外，絕對不可將壓舌板或任何異物硬塞進正在緊閉或抽搐的患者口中，這極可能會打斷牙齒，碎片掉入氣管導致致命窒息（選項B禁忌錯誤）。
For a patient at high risk of tonic-clonic seizures, safety precautions focus on preventing aspiration and physical injury. Oxygen and suction equipment must be immediately available to manage secretions and maintain airway patency. The bed should be lowered with padded side rails to prevent falls and impact injuries, and tight clothing around the neck should be loosened to avoid restricting the airway.
過去台美均曾存在「發作時咬壓舌板防咬舌」的舊觀念，但近年台美皆已根據 EBP (實證醫學) 強烈廢除此危險動作。NCLEX與台灣國考皆把「禁止塞入咬合板」列為絕對必考的護理常規指標。