護理師照護有癲癇病史的病人，在病人發生癲癇時，哪些措施對維護安全至關重要？(選所有適合的)
A nurse is caring for a client with a history of seizures. Which actions are essential to maintain 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 into the mouth將包覆軟墊的壓舌板置入口中
- CTime the duration of the seizure✓ 正解記錄癲癇發作的持續時間
- DClear the surrounding area of dangerous objects✓ 正解清除周遭危險物品
- EApply physical restraints to prevent injury實施身體約束以防止受傷
癲癇發作時的護理重點在於確保呼吸道暢通（Airway）並防止病人受傷（Safety）。首要原則是「保護而非限制」，透過側臥位（Recovery position）防止嘔吐物誤吸，並移開周遭危險物以防碰撞。記錄發作時間對於評估癲癇重積狀態（Status epilepticus）及後續醫療決策至關重要。強行約束或放置異物於口中均會導致骨折、牙齒脫落或呼吸道阻塞，違反安全原則。
Priority nursing actions during a seizure include placing the client in a lateral position to maintain a patent airway and clearing the surrounding area of hazardous objects to prevent injury. It is essential to time the seizure duration for medical evaluation, while avoiding inserting objects into the mouth or applying physical restraints.
台灣與美國臨床做法一致，強調「嚴禁約束」與「嚴禁硬物塞口」。美國護理教育更強調記錄發作的型態（如強直性、陣攣性）及發作後的意識狀態（Postictal state）。