— 生理適應 · EASY · MCQ —
照顧一位有癲癇病史的病人，病人突然開始全身強直陣攣發作。護理師的第一動作為何？
A nurse is caring for a client with a history of seizures. The client suddenly begins to experience a tonic-clonic seizure. What should the nurse do first?
- AInsert a bite block插入咬口器
- BTurn the client to the side✓ 正解將病人轉為側臥
- CAttempt to restrain the client's limbs嘗試約束病人的四肢
- DCall for help immediately立即尋求協助
— Explanation · 中文詳解 —
全身強直陣攣發作（Tonic-clonic seizure）時，護理師的首要責任是維護病人安全。第一優先動作是將病人側臥（Turn to side），這能確保口腔分泌物順利流出，防止舌頭後墜阻塞呼吸道，並預防吸入性肺炎。在發作過程中，絕對不可強行塞入任何物件（如壓舌板），以免造成牙齒斷裂或氣道阻塞，也不應約束病人的肢體，以免造成骨折。
Continuous bubbling in the water-seal chamber of a chest drainage system typically indicates an air leak within the system connections or tubing. The priority nursing action is to inspect the entire setup for loose fittings or damage to ensure the system remains airtight and functions correctly.