— 心理社會完整性 · HARD · SATA —
護理師應針對急性酒精戒斷症狀監測哪些跡象？（選所有適合的）
Which signs or symptoms should the nurse monitor for in a client experiencing acute alcohol withdrawal? (Select all that apply.)
- ADiaphoresis✓ 正解盜汗
- BBradycardia心搏過緩
- CTremors✓ 正解震顫
- DAuditory hallucinations✓ 正解聽覺幻覺
- EHypotension低血壓
— Explanation · 中文詳解 —
急性酒精戒斷會出現交感神經亢奮症狀，包含出汗、震顫、幻覺、心搏過速及高血壓，而非抑制症狀。若出現幻覺或嚴重震顫，暗示酒精戒斷譫妄（DTs）風險。護理重點在於監測生命徵象、預防癲癇及提供環境保護，而非降低心跳或血壓的措施。
Acute alcohol withdrawal produces sympathetic hyperactivity, including diaphoresis, tremors, hallucinations, tachycardia, and hypertension, rather than depressive findings. The presence of hallucinations or severe tremors suggests risk for delirium tremens (DTs). Nursing priorities include monitoring vital signs, preventing seizures, and providing environmental safety, rather than measures aimed at lowering heart rate or blood pressure.
✦ 台美臨床差異
美國醫院常用 CIWA-Ar 量表進行結構化評估並給予對應藥物，台灣臨床亦逐漸導入類似量表使用。