— 降低風險 · EASY · MCQ —
一位病人發生大發作癲癇（Grand mal seizure），護理師應首要採取的行動為何？
A nurse is caring for a client experiencing a grand mal seizure. Which of the following actions should the nurse perform first?
- ATurn the client to the side✓ 正解將病人轉為側臥
- BRestrain the client's limbs約束病人的肢體
- CAdminister IV lorazepam給予靜脈注射勞拉西泮
- DInsert a bite block into the client's mouth將咬塊放入病人口中
— Explanation · 中文詳解 —
大發作癲癇（Grand mal seizure）發生時，護理師的首要任務是確保病人的呼吸道通暢與預防外傷。將病人轉為側臥位（side-lying）可以讓口腔分泌物順利流出，防止舌頭阻塞呼吸道或發生吸入性肺炎。千萬不可強行插入異物或約束肢體，以免造成牙齒斷裂或骨折。這是癲癇發作時最關鍵的護理安全行動。
During a grand mal seizure, the priority is maintaining a patent airway and preventing aspiration of secretions. Turning the client to the side facilitates drainage and reduces the risk of choking, whereas restraining limbs or inserting objects can cause injury.