— 安全與感染控制 · MEDIUM · MCQ —
護理師照顧一位發生大發作癲癇的病人。哪項動作應立即採取？
A nurse is caring for a client experiencing a grand mal seizure. Which action should the nurse take immediately?
- AAttempt to transfer the client to a bed if they are on the floor若客戶在地上，嘗試將其轉移至床上
- BInsert a padded tongue blade into the client's mouth將軟墊舌片插入客戶口中
- CTurn the client to their side and protect their head✓ 正解將客戶轉為側臥並保護其頭部
- DRestrain the client's limbs to prevent injury約束客戶四肢以預防受傷
— Explanation · 中文詳解 —
癲癇發作時的護理重點是「保護病人不被環境傷害」以及「維持呼吸道通暢」。側臥（C）可防止誤吸，保護頭部則避免碰撞。絕對禁止插入任何東西進口中（B），因為會造成牙齒斷裂或阻塞呼吸道；束縛（D）會增加骨折風險；切勿搬動（A）以免受傷。
The immediate priority during a grand mal seizure is to protect the client’s airway and prevent injury by turning them to their side and cushioning their head. Nurses must never insert objects into the mouth or restrain the client’s limbs, as these actions can cause dental damage, airway obstruction, or fractures.
✦ 台美臨床差異
台美皆強調不塞東西進口中的原則，台灣醫療機構宣導亦明確指出「不強壓、不移動、不放入物品」。