— 照護管理 · EASY · MCQ —
護理師督導照服員照顧一位有癲癇病史的病人。照服員的哪項行為需要立即介入？
A nurse is supervising an assistive personnel (AP) providing care to a client with a history of seizures. Which action by the AP requires immediate intervention?
- AClearing the environment of hard objects清除環境中的硬物
- BLoosening the client's clothing around the neck鬆開病人頸部的衣物
- CTurning the client to the side during a seizure在癲癇發作期間將病人轉為側臥
- DPlacing a tongue blade in the client's mouth during a seizure✓ 正解在癲癇發作期間將壓舌板放入病人口中
— Explanation · 中文詳解 —
癲癇發作時絕對不可強行將異物（如壓舌板）放入病人口中，這極易導致牙齒斷裂或阻塞呼吸道。護理重點在於保護病人免受外傷，包括頭部保護、側臥以利分泌物流出，並確保環境安全。若看到照服員嘗試放入壓舌板，必須立即阻止並教育正確觀念。
Placing a tongue blade in a seizing client's mouth is strictly contraindicated as it can cause oral trauma, tooth fracture, or airway obstruction. Nursing priority during a seizure is to protect the client from injury by clearing the environment, loosening restrictive clothing, and positioning the client on their side to facilitate drainage and prevent aspiration.
✦ 台美臨床差異
台美臨床皆禁止癲癇發作期使用壓舌板；美國護理養成對此教育極嚴，台灣臨床部分舊式照護觀念有時仍需矯正。