— 照護管理 · MEDIUM · SATA —
護理師照顧癲癇病史的病人，應執行哪些照護措施？（選所有適合的）
A nurse is caring for a client with a history of seizures. Which interventions should the nurse implement? (Select all that apply.)
- APad the side rails of the bed✓ 正解為床欄加裝軟墊
- BKeep a suction setup at the bedside✓ 正解在床邊備妥抽吸設備
- CInsert a tongue depressor during the seizure在發作期間插入壓舌板
- DMaintain the bed in the lowest position✓ 正解將病床保持在最低位置
- EPlace the client on their side during a seizure✓ 正解在發作期間將病人置於側臥位
— Explanation · 中文詳解 —
癲癇（Seizure）照護的核心目標是維護病人安全、防止受傷，並確保氣道通暢。護理措施應包含環境安全防護與發作時的即時處置。加裝軟墊與低床位能降低抽搐導致的碰撞風險；側臥位（recovery position）則是為了防止口腔分泌物或嘔吐物造成吸入性肺炎（aspiration pneumonia）。抽吸裝置是為了在發作後清除呼吸道阻塞物。臨床思路應優先考慮預防物理性傷害（Safety）與維持呼吸道（Airway）。
Assessments for fall risk in the elderly should include history of recent falls, use of antihypertensive medications, impaired visual acuity, and presence of orthostatic hypotension, as these significantly increase the likelihood of falling.