— 照護管理 · EASY · MCQ —
護理師監督助理人員（AP）照護一位有癲癇病史的病人。下列哪項 AP 的行為需要護理師介入？
A nurse is supervising an assistive personnel (AP) providing care to a client with a history of seizures. Which action by the AP requires the nurse to intervene?
- ATurning the client onto their side將病人轉向側臥
- BPlacing a tongue blade in the client's mouth during a seizure✓ 正解在病人抽搐期間將舌片放入口中
- CLoosening restrictive clothing around the client's neck鬆開病人頸部周圍緊束的衣物
- DRecording the duration of the seizure activity記錄抽搐活動的持續時間
— Explanation · 中文詳解 —
癲癇發作時絕對不可放置壓舌板或任何物體於病人口中，此舉極易導致牙齒斷裂或阻塞呼吸道。護理重點在於保護頭部、側臥以防止吸入性肺炎、保持呼吸道暢通並記錄發作時間。AP 的錯誤行為會造成人為傷害，必須立即阻止。
Placing a tongue blade in a seizing client's mouth is dangerous and requires immediate intervention, as it can cause oral trauma or airway obstruction. Appropriate care includes turning the client to the side to prevent aspiration, loosening restrictive clothing, and documenting the seizure duration.
✦ 台美臨床差異
台美臨床指引皆嚴格禁止在發作時放壓舌板，但在台灣部分傳統觀念仍存，需由護理師加強衛教 AP。