— 降低風險 · MEDIUM · SATA —
護理師照護一位發生大發作（grand mal seizure）的病人。下列哪些措施是適當的？（選所有適合的）
A nurse is caring for a client who is having a grand mal seizure. Which actions are appropriate for the nurse to perform? (Select all that apply.)
- APlace a padded tongue blade into the mouth將包紮過的舌片放入口中
- BTurn the client to their side✓ 正解將病患轉為側臥
- CLoosen restrictive clothing✓ 正解鬆開緊迫的衣物
- DTime the duration of the seizure✓ 正解記錄發作持續時間
- ERestrict the client's movements to prevent injury限制病患動作以預防受傷
— Explanation · 中文詳解 —
大發作（Grand mal seizure）護理的核心在於「預防受傷」與「維持呼吸道」。發作時應側臥以防誤吸，鬆開緊身衣物以利呼吸，並全程計時以評估是否進入癲癇持續狀態（status epilepticus）。絕對禁止將異物放入病人口中，以免導致牙齒斷裂或阻塞呼吸道，亦不可強行約束肢體，以免造成骨折。
During a grand mal seizure, the priority is maintaining the airway and preventing injury by turning the client to their side and loosening restrictive clothing. The nurse should time the seizure to assess for status epilepticus but must never force objects into the mouth or restrain the client, as these actions can cause trauma or fractures.