— 降低風險 · MEDIUM · MCQ —
當病人發生全身性強直陣攣性癲癇發作時，護理師的首要行動為何？
Which action is the nurse's priority when a client experiences a generalized tonic-clonic seizure?
- ARestrain the client's extremities約束病人的四肢
- BProtect the client's head from injury✓ 正解保護病人的頭部免受傷害
- CAdminister an oral anticonvulsant給予口服抗癲癇藥物
- DInsert a padded tongue blade into the mouth將包有軟墊的壓舌板插入口中
— Explanation · 中文詳解 —
癲癇發作期間護理師首要目標是維持病人安全，避免其頭部撞擊硬物造成二次外傷。現行指引嚴禁在發作中塞入任何物品（如壓舌板），以免造成口腔損傷或呼吸道阻塞。強行約束四肢可能導致骨折，應移除周邊危險物品即可。
To manage increased intracranial pressure (ICP), the nurse should elevate the head of the bed to 30 degrees and maintain the neck in a neutral, midline position to promote venous drainage. Stool softeners are also administered to prevent straining, which increases intra-abdominal pressure and subsequently raises ICP.
✦ 台美臨床差異
台灣部分臨床護理師過去受訓可能會有塞入壓舌板的習慣，但現代實證醫學已全面導向保護性護理，美台一致。