— 生理適應 · EASY · SATA —
照護有癲癇病史的病人時，下列哪些護理措施是適當的？（選所有適合的）
Which of the following nursing actions are appropriate when caring for a client with a history of seizure disorders? (Select all that apply.)
- AKeep a suction setup at the bedside✓ 正解在床邊準備抽吸設備
- BPlace padded side rails on the bed✓ 正解在床欄上加裝軟墊
- CRestrict all fluid intake限制所有液體攝取
- DTurn the client to the side during a seizure✓ 正解在發作期間將病人轉向側臥
- EInsert a tongue blade to prevent tongue biting插入壓舌板以防止咬傷舌頭
— Explanation · 中文詳解 —
癲癇發作的護理核心在於「保護病人安全」與「維持呼吸道通暢」。當病人發生癲癇時，護理師應立即移除周圍危險物，協助病人側躺以利分泌物排出，並備妥抽吸設備清理呼吸道。絕對禁止強行打開病人的嘴或放入任何異物，以免造成口腔組織損傷或牙齒斷裂。此題考驗護理師對癲癇發作時安全護理措施的熟悉度，優先順序為保持呼吸道暢通（ABC原則）與防止受傷。
Appropriate nursing actions include keeping suction equipment at the bedside for airway management, placing padded side rails to prevent injury, and turning the client to the side during a seizure to prevent aspiration. Fluid restriction is unnecessary, and inserting objects into the mouth is dangerous and contraindicated.
✦ 台美臨床差異
美國臨床非常強調「不要強行約束或放入異物於癲癇病人嘴中」，此點與台灣臨床教育一致，但美國護理評估更重視在病人發作後記錄「發作後的意識狀態與神經學檢查（Post-ictal assessment）」。