— 降低風險 · MEDIUM · SATA —
護理師照顧一位有癲癇病史的病人，照護計畫應包含哪些措施？（選所有適合的）
A nurse is caring for a client with a history of seizures. Which interventions should the nurse include in the care plan? (Select all that apply.)
- APad the side rails of the bed✓ 正解為床欄加裝護墊
- BKeep a suction setup at the bedside✓ 正解在床邊準備抽吸設備
- CPlace a padded tongue blade at the bedside在床邊放置包布舌壓板
- DEnsure O2 equipment is functioning✓ 正解確保氧氣設備運作正常
- EMaintain the bed in the lowest position✓ 正解保持病床處於最低位置
— Explanation · 中文詳解 —
癲癇發作時的護理重點在於預防受傷與維護呼吸道暢通。床欄加護墊防碰撞、床保持低位防跌落、吸痰設備與氧氣設備隨時備用以供發作後使用。現代護理觀點嚴禁使用舌板（C），因為這會導致口腔損傷及呼吸道阻塞，已被證實是錯誤的介入措施。
Care plans should prioritize safety and airway management by padding side rails, maintaining the bed in the lowest position, and keeping suction and oxygen equipment readily available. Modern nursing standards strictly prohibit inserting objects into the mouth, such as tongue blades, to prevent dental injury and airway obstruction.
✦ 台美臨床差異
美台兩地護理標準均已更新，皆不推薦使用舌板，但國內部分老舊單位可能仍有殘存的錯誤習慣。