— 降低風險 · MEDIUM · MCQ —
護理師照護一位有癲癇病史的病人。若病人開始癲癇發作，下列哪項護理措施為最高優先？
A nurse is caring for a client with a history of seizures. Which intervention is the highest priority if the client begins to seize?
- AProtect the client from injury✓ 正解保護個案免受傷害
- BRestrain the client's extremities約束個案的四肢
- CInsert a padded tongue blade插入包覆軟墊的壓舌板
- DAdminister IV lorazepam靜脈注射勞拉西泮
— Explanation · 中文詳解 —
癲癇發作時，護理師的首要任務是確保病人的安全，防止病人因不受控制的肢體抽搐而撞傷或摔傷。這包括移除周圍危險物、保護頭部，並保持側臥位（Recovery position）以維持呼吸道通暢。嚴禁強行約束肢體或嘗試塞入任何物品入喉，因為這些行為反而會造成骨折或牙齒斷裂，導致誤吸（Aspiration）。
The highest priority during a seizure is protecting the client from injury by clearing the area of hazards and padding the head to prevent trauma. Restraining the client or inserting objects into the mouth is contraindicated as it increases the risk of fractures, dental damage, and aspiration.