— 生理適應 · EASY · MCQ —
當病患出現全身僵直陣攣性癲癇發作時，護理師的首要行動為何？
A nurse is caring for a patient experiencing a tonic-clonic seizure. Which nursing action is the highest priority?
- AInsert a bite block into the mouth將咬合板置入口中
- BAdminister IV lorazepam immediately立即給予靜脈注射勞拉西泮
- CRestrain the patient's limbs約束病人肢體
- DTurn the patient to the side✓ 正解將病人轉為側臥
— Explanation · 中文詳解 —
癲癇發作（Seizure）時，護理師的首要任務是確保病人的呼吸道通暢（ABC 優先原則）。將病人轉向側臥（Side-lying position）可以防止舌頭後墜堵塞氣道，並有助於口腔分泌物流出，減少吸入性肺炎的風險。嚴禁在癲癇發作時強行放入異物（咬合板）或束縛肢體，以免造成骨折、牙齒斷裂或口腔損傷。
The highest priority during a tonic-clonic seizure is maintaining a patent airway by turning the client to the side to prevent aspiration of secretions and tongue obstruction. Inserting objects into the mouth or restraining the client can cause injury and is strictly contraindicated.