一位有酒精成癮史的病人因戒斷症狀入院，護理師應最關注哪項評估結果？
A client with a history of alcohol use disorder is admitted for detoxification. Which assessment finding is most concerning to the nurse?
- ANausea and abdominal cramping噁心和腹部痙攣
- BElevated blood pressure and tremors血壓升高和震顫
- CMild anxiety and irritability輕度焦慮和易怒
- DVisual hallucinations and disorientation✓ 正解幻視和定向力障礙
酒精戒斷症狀中，意識混亂、幻覺與定向力喪失是「瞻妄（Delirium Tremens, DTs）」的預兆，這是酒精戒斷中最嚴重的併發症，可能導致生命危險（如癲癇、心血管崩潰）。其他選項如震顫、焦慮、腸胃不適雖是常見戒斷症狀，但 DTs 具有極高的致命性，需優先處置。
Among alcohol withdrawal symptoms, confusion, hallucinations, and disorientation are precursors to Delirium Tremens (DTs), which is the most severe complication of alcohol withdrawal and can be life-threatening (e.g., seizures, cardiovascular collapse). Other options such as tremors, anxiety, and gastrointestinal discomfort are common withdrawal symptoms, but DTs carry an extremely high mortality risk and must be prioritized.
美國醫護對於 DTs 的預防性給藥（如 Benzodiazepines）Protocol 非常嚴格；台灣臨床依賴醫師判斷，護理師需主動回報早期徵兆。