— 生理適應 · EASY · MCQ —
下列哪項護理行動適用於正處於陣攣性發作的病人？
Which of the following nursing actions is appropriate for a client experiencing a tonic-clonic seizure?
- ARestrain the client's limbs to prevent injury約束病人四肢以預防受傷
- BPlace a padded tongue blade in the client's mouth在病人口中放入包墊的壓舌板
- CImmediately insert an oral airway device立即插入口咽通氣管
- DTurn the client to the side and clear the area✓ 正解將病人轉為側臥並清除周圍區域
— Explanation · 中文詳解 —
癲癇發作時的優先護理為保護病患免於受傷（Safety）。側臥可防止呼吸道阻塞（吸入性嘔吐），並清除周圍硬物以防碰撞。強制約束肢體反而易導致骨折；在口腔插入物品已證實會造成牙齒損傷，現行實證護理嚴禁此行為。
The priority nursing action during a tonic-clonic seizure is to turn the client to the side and clear the surrounding area to maintain a patent airway and prevent aspiration. Restraining limbs or inserting objects into the mouth is contraindicated as it increases the risk of injury, including fractures and dental damage.
✦ 台美臨床差異
目前台美兩地皆嚴格執行「不放入異物」的癲癇護理標準，觀念趨於一致。