— 生理適應 · MEDIUM · SATA —
一位病人發生強直陣攣性癲癇，護理師應採取哪些措施？（選所有適合的）
A client is experiencing a tonic-clonic seizure. Which actions should the nurse perform? (Select all that apply.)
- AInsert a padded tongue blade into the mouth將包墊的舌片放入口中
- BProtect the head by placing a pad under it✓ 正解在頭部下方放置墊子以保護頭部
- CTurn the client to the side✓ 正解將病人轉向側臥
- DLoosen restrictive clothing✓ 正解鬆開限制性衣物
- ERestrain the limbs to prevent injury約束肢體以防止受傷
— Explanation · 中文詳解 —
癲癇發作時的護理核心是保護病人免於受傷與維持呼吸道暢通。保護頭部、側臥以防止吸入性肺炎、鬆開束縛衣物皆是正確處置。絕對禁止將任何物品放入病人口中（如壓舌板），因容易造成牙齒斷裂或氣道阻塞。束縛肢體會導致肌肉或骨骼損傷，亦不可執行。
The priority during a tonic-clonic seizure is to protect the client from injury and maintain a patent airway. This includes padding the head, turning the client to the side to prevent aspiration, and loosening restrictive clothing, while avoiding inserting objects into the mouth or restraining limbs.
✦ 台美臨床差異
美台護理標準一致，兩者皆強調「絕對不要」在發作時放壓舌板，這是現代護理教育的核心共識。