— 降低風險 · MEDIUM · SATA —
護理師為有陣攣性癲癇史的病人計劃照護，應實施哪些安全防護措施？（選所有適合的）
A nurse is planning care for a client with a history of tonic-clonic seizures. Which safety precautions should be implemented? (Select all that apply.)
- AKeep padded side rails up✓ 正解保持加墊床欄升起
- BMaintain suction equipment at the bedside✓ 正解在床邊準備抽吸設備
- CKeep a padded tongue blade at the bedside在床邊放置加墊壓舌板
- DEnsure oxygen is available✓ 正解確保氧氣可用
- EPlace the bed in the lowest position✓ 正解將床調整至最低位置
— Explanation · 中文詳解 —
陣攣性癲癇（Tonic-clonic seizure）照護重點在於「防傷、防窒息」。加墊床欄可防止撞傷；床位降至最低可防墜床；維持抽吸設備與氧氣在床邊，是為了在發作後（Post-ictal phase）若病人出現嘔吐或呼吸道阻塞時能立即處理。現代護理實證已證實不應在病人發作時強行放入任何硬物（如壓舌板），以免造成牙齒斷裂或誤入氣道。
Safety precautions for a client with tonic-clonic seizures include keeping padded side rails up to prevent trauma, maintaining suction and oxygen at the bedside to manage secretions and hypoxia, and lowering the bed to minimize fall injuries. Tongue blades should never be placed in the mouth as they pose a risk of dental injury and airway obstruction.