— 降低風險 · MEDIUM · MCQ —
護理師照護一位有癲癇病史的病人。在強直陣攣性癲癇發作時，哪項介入措施優先順序最高？
A nurse is providing care to a client with a history of seizures. Which intervention is the highest priority during an active tonic-clonic seizure?
- AAdminister an emergency dose of phenytoin IV靜脈注射急救劑量的苯妥英
- BRestrain the client's limbs to prevent injury約束病人四肢以預防受傷
- CInsert a padded tongue blade into the mouth將包紮過的舌片置入口中
- DProtect the client's head and maintain a patent airway✓ 正解保護病人頭部並維持呼吸道暢通
— Explanation · 中文詳解 —
癲癇發作時安全第一，首重保護頭部免於撞擊，並確保呼吸道暢通（側臥以利分泌物引流）。約束肢體可能造成骨折或肌肉損傷，禁止插入任何異物（如壓舌板）以免阻塞氣道或導致病人咬碎異物。給藥通常是發作後的醫療處置。
During an active tonic-clonic seizure, the highest priority is to protect the client’s head from injury and maintain a patent airway, often by positioning the client on their side. Restraints should never be used as they can cause fractures, and objects should not be placed in the mouth due to the risk of airway obstruction or dental injury. Medication administration typically occurs after the seizure stabilizes.
✦ 台美臨床差異
台美皆嚴格執行「發作中不置入異物」的原則，這已成為標準護理教學流程。