— 照護管理 · MEDIUM · MCQ —
護理師督導一名照顧癲癇病史病人的新進護理師。下列哪項新進護理師的行為需要護理師立即介入？
A nurse is supervising a newly licensed nurse who is caring for a client with a history of seizures. Which action by the new nurse requires immediate intervention?
- ATurning the client onto their side during a seizure在抽搐期間將個案轉為側臥
- BPlacing a padded tongue blade at the bedside✓ 正解在床邊放置包墊的壓舌板
- CClearing the area around the bed of hard objects清除床週圍的硬物
- DLoosening the client's restrictive clothing鬆開個案的限制性衣物
— Explanation · 中文詳解 —
癲癇發作的護理核心在於「保護病人免於受傷」與「維持呼吸道通暢」。在發作過程中，強行撬開牙關放置壓舌板已被現代實證護理明確禁止，因為這極易導致牙齒斷裂、軟組織受傷，甚至造成碎裂物阻塞呼吸道。護理師應採取側臥位（Side-lying position）防止誤吸，並移除周圍危險物品，而非試圖介入病人的口腔。
Placing a tongue blade in a seizing client's mouth is contraindicated as it poses a high risk of dental injury, soft tissue damage, and airway obstruction. Nursing care should focus on protecting the client from physical harm and maintaining airway patency through lateral positioning and clearing the environment.
✦ 台美臨床差異
台灣部分老一輩醫療人員或一般民眾仍有「發作要塞東西進嘴裡」的迷思，但在美國 NCLEX 標準中，嚴格禁止任何異物放入癲癇病人口中，這是非常重要的考點。