# 個案在床上開始發生全身性癲癇發作。請將護理措施排成正確順序。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393871&lang=zh-tw  
> language: zh-TW  
> subject: Accident/Error/Injury Prevention  
> category: SIPC

## 題目

個案在床上開始發生全身性癲癇發作。請將護理措施排成正確順序。

留在個案身旁、呼叫協助並開始計時發作。

可能時將個案輕柔轉向側臥並保持呼吸道通暢。

發作停止後評估呼吸道、呼吸、生命徵象與神經狀態。

移除附近危險物並保護頭部，但不約束個案。

記錄發作特徵與發作後發現。

## 解析

護理師首先留在個案旁、呼叫協助並計時。接著在不約束的情況下保護個案避免受傷，可能時協助側臥維持呼吸道。發作停止後，在記錄前先評估呼吸道、呼吸、生命徵象與神經狀態。正確順序為 3, 4, 1, 5, 2。

## 深入解析

臨床判斷
發作中要預防受傷並維持呼吸道安全，不要強行限制動作或把物品放入口中。

記憶重點
留下、保護、側臥、評估、記錄。

## 臨床情境

實務指引
癲癇急救指引強調留在身旁、保持安全、計時、可能時轉側，以及避免約束或放物品入口中。

注意
發作持續、反覆發作、受傷、懷孕或呼吸困難需要緊急升級處置。

## 重要概念

- **全身性癲癇發作** — 涉及大腦兩側的發作，可能影響意識與動作。
- **發作後狀態** — 發作後恢復期，常有混亂、嗜睡或神經變化。
- **呼吸道保護** — 在事件中或之後協助維持呼吸並降低吸入風險的措施。

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