— 降低風險 · EASY · SATA —
護理師照護一位有癲癇病史的病人，應採取哪些措施以減少受傷風險？（選所有適合的）
A nurse is caring for a client with a history of seizures. Which actions should the nurse include in the care plan to reduce the risk of injury? (Select all that apply.)
- AKeep padded side rails up at all times✓ 正解隨時保持加墊床欄升起
- BKeep a tongue blade at the bedside在床邊備置壓舌板
- CPlace the bed in the lowest position✓ 正解將病床保持在最低位置
- DMaintain suction equipment at the bedside✓ 正解在床邊備妥抽吸設備
- EEnsure the call light is within reach✓ 正解確保呼叫器在可觸及範圍內
— Explanation · 中文詳解 —
癲癇護理重點在於環境安全與預防窒息。床欄加軟墊可防止碰撞受傷；床位放低預防跌落；放置抽吸設備以利發作後清除呼吸道分泌物；呼叫器在手方便緊急求救。嚴禁放置壓舌板，因發作時強行放置會導致牙齒斷裂或阻塞呼吸道。
To minimize injury risk during a seizure, the nurse should keep padded side rails up to prevent trauma, lower the bed to reduce fall height, and ensure suction equipment is available to manage secretions. The call light must be within reach for safety, but tongue blades should never be placed in the mouth as they pose a risk of airway obstruction and dental injury.
✦ 台美臨床差異
台灣醫院目前仍有部分舊制強調壓舌板，但現代護理教學已與美國同步，全面禁止於床邊放置壓舌板。