— 安全與感染控制 · EASY · MCQ —
護理師為癲癇發作高風險病人執行安全預防措施，下列何者為優先順序最高的動作？
Which action is the highest priority for a nurse implementing seizure precautions for a client at risk for tonic-clonic seizures?
- AMaintaining the client in a supine position讓病人保持仰臥姿勢
- BPadding the side rails of the bed✓ 正解為床欄加墊
- CRestraining the client's extremities約束病人的四肢
- DPlacing an oral airway at the bedside在床邊放置口咽通氣道
— Explanation · 中文詳解 —
癲癇預防的核心是環境安全。床欄加裝軟墊可防止病人發作時撞擊床欄導致頭部外傷或骨折。口咽通氣道不應強行塞入，可能造成牙齒脫落或阻塞呼吸道；約束病患會導致躁動且無助於預防受傷；仰臥位容易導致舌頭後倒阻塞呼吸，發作時應採側臥位以利引流。
Padding the side rails is the highest priority action to prevent physical injury to the client during a tonic-clonic seizure. Restraints should be avoided as they may cause fractures, and objects should never be forced into the mouth, while positioning the client on their side helps maintain a patent airway.
✦ 台美臨床差異
美台臨床皆強調保護頭部為首要，但在台灣病房設備中，加裝軟墊有時需特別申請或使用床單包覆，護理評估一致。