— 降低風險 · MEDIUM · MCQ —
護理師照護一位有癲癇病史的病人。下列哪項措施應在病人發生強直陣攣性發作時執行？
A nurse is caring for a client with a history of seizures. Which of the following interventions should the nurse perform during a tonic-clonic seizure?
- AAttempt to open the airway with a jaw-thrust maneuver嘗試以下顎推舉動作開放呼吸道
- BInsert a padded tongue blade into the mouth將包覆軟墊的舌片置入口中
- CTurn the client to the side✓ 正解將病人轉為側臥
- DRestrain the client's extremities約束病人的四肢
— Explanation · 中文詳解 —
強直陣攣發作時，護理重點為維護呼吸道通暢與防止外傷。採側臥姿（recovery position）可防止嘔吐物吸入與舌頭後墜阻塞呼吸道。絕對禁止強行打開口腔或置入任何物體，這會造成牙齒脫落或呼吸道阻塞；強行束縛可能導致骨折或肌肉撕裂傷。
During a tonic-clonic seizure, the priority is to maintain a patent airway and prevent aspiration of secretions or vomitus. Turning the client to the side facilitates drainage and prevents the tongue from obstructing the airway. Interventions such as inserting objects into the mouth or restraining the client are contraindicated as they can cause trauma, dental injury, or fractures.
✦ 台美臨床差異
台美臨床指引皆強調癲癇發作時禁放壓舌板，但在台灣民俗習慣中，家屬仍常試圖置入物體，需加強衛教。