— 安全與感染控制 · MEDIUM · MCQ —
病人正在經歷大發作癲癇（grand mal seizure）。護理師應優先採取哪項行動？
A client is experiencing a grand mal seizure. Which action should the nurse take first?
- AInsert a tongue blade to prevent tongue biting插入壓舌板以防止咬舌
- BTurn the client to the side✓ 正解將病人轉為側臥
- CAdminister IV lorazepam immediately立即靜脈注射勞拉西泮
- DRestrain the client's extremities約束病人的四肢
— Explanation · 中文詳解 —
癲癇大發作時，護理師的首要任務是病人安全（Safety）與保持呼吸道通暢（Airway）。病人發作時可能出現意識喪失、牙關緊閉與口水增多，側臥位（Side-lying position）能利用重力使口水或嘔吐物流出，防止誤吸（Aspiration）。護理師應陪伴病人，保護頭部，確保環境安全，直到發作結束。
The priority during a grand mal seizure is maintaining a patent airway and preventing aspiration of secretions or vomit. Turning the client to the side utilizes gravity to drain fluids away from the airway, ensuring safety while protecting the head from injury.