— 安全與感染控制 · HARD · MCQ —
護理師進入病房發現病人癲癇發作後倒在地上，優先護理措施為何？
A nurse enters a room and finds a client on the floor following a seizure. What is the priority nursing action?
- ACall for immediate assistance立即尋求協助
- BAssess the airway and breathing✓ 正解評估呼吸道與呼吸
- CPlace a padded tongue blade in the client's mouth在病人口中放置加墊的壓舌板
- DAttempt to restrain the client's movements嘗試限制病人的動作
— Explanation · 中文詳解 —
癲癇發作後的首要任務是確保 ABC（呼吸道、呼吸、循環）。檢查呼吸道是否通暢是重中之重，防止誤吸。約束動作無效且具傷害性，壓舌板已不再建議使用，避免造成口腔損傷。呼叫協助固然重要，但需先確認病人當下生命跡象。
The priority nursing action is to assess the client's airway and breathing to ensure patency and adequate oxygenation immediately after the seizure. Post-ictal clients are at high risk for airway obstruction due to secretions, tongue fall-back, or residual muscle relaxation. While calling for assistance is important, establishing a secure airway takes precedence to prevent hypoxia and aspiration.
✦ 台美臨床差異
兩地急救指引對癲癇處置皆已修正，不再放置壓舌板。