— 安全與感染控制 · MEDIUM · SATA —
護理師照護癲癇病人，應實施哪些安全措施？（選所有適合的）
A nurse is caring for a client with a Seizure disorder. Which safety measures should be implemented? (Select all that apply.)
- AKeep a padded tongue blade at the bedside在床邊備有包軟墊的舌壓板
- BMaintain bed in the lowest position✓ 正解維持病床在最低位置
- CHave suction equipment ready at the bedside✓ 正解在床邊準備好抽吸設備
- DKeep side rails up and padded✓ 正解保持床欄拉起並加墊
- ERestrain the client during the seizure在癲癇發作期間約束病人
— Explanation · 中文詳解 —
癲癇發作時的護理核心在於「保護病人免於受傷」與「維持呼吸道暢通」。護理師應預防病人跌倒、撞擊頭部或咬傷舌頭，但必須避免過度干預。正確措施包括維持環境安全（如床欄加墊）、維持床位低位以利必要時移至地面，以及準備抽吸設備以應對發作後可能出現的嘔吐或分泌物。禁忌行為包括強行約束（可能導致骨折）或在口中放置任何異物（可能造成牙齒損傷或氣道阻塞）。
Safety measures include keeping the bed in the lowest position to prevent fall injuries, padding side rails to protect against impact, and having suction equipment ready to maintain airway patency. Restraints and tongue blades are contraindicated due to risks of fracture and dental injury.
✦ 台美臨床差異
在美國臨床實務中，預防跌倒與保護隱私（如床欄加墊）被視為極其嚴格的 Safety Protocols，護理師需確保床欄有適當的 Padding，否則可能構成醫療疏失。