— 生理適應 · EASY · SATA —
護理師照護癲癇病史的病人，當發生強直陣攣性癲癇時，應採取哪些措施？（選所有適合的）
A nurse is caring for a client with a history of seizures. Which interventions should the nurse implement during a tonic-clonic seizure? (Select all that apply.)
- ATurn the client to the side✓ 正解將病人轉為側臥
- BInsert a padded tongue blade插入帶襯墊的壓舌板
- CLoosen restrictive clothing✓ 正解鬆開緊束的衣物
- DTime the duration of the seizure✓ 正解記錄癲癇發作的持續時間
- EApply soft restraints施加軟性約束
— Explanation · 中文詳解 —
強直陣攣性癲癇（Tonic-Clonic Seizure）發作時，護理重點為「預防受傷」與「維持呼吸道」。護理師應確保病人頭部下方墊有軟物，將病人側臥以利分泌物流出，移除周圍硬物，並鬆開領口衣物。全程需記錄發作時間，因為若發作超過 5 分鐘，可能進展為癲癇持續狀態（Status Epilepticus），需使用急救藥物。
During a tonic-clonic seizure, the nurse should turn the client to the side to facilitate drainage of secretions and prevent aspiration. It is essential to loosen restrictive clothing to maintain airway patency and time the seizure duration to monitor for status epilepticus. Inserting objects into the mouth or applying restraints is contraindicated as it poses a significant risk of injury.