— 心理社會完整性 · MEDIUM · SATA —
護理師為一位高齡長者進行心智狀態檢查。下列哪些發現符合譫妄（delirium）的特徵？（選所有適合的）
A nurse is performing a mental status examination on an older adult client. Which findings are consistent with the presence of delirium? (Select all that apply.)
- ARapid fluctuation in level of consciousness✓ 正解意識水平迅速波動
- BProgressive, slow decline in cognitive function認知功能逐漸、緩慢下降
- CInability to maintain attention✓ 正解無法維持注意力
- DAcute onset of symptoms✓ 正解症狀急性發作
- EStable orientation throughout the day全天定向力穩定
— Explanation · 中文詳解 —
譫妄的核心特徵在於發作迅速且具波動性。病人常表現出注意力難以集中、意識狀態起伏及急性發作。相對地，慢性認知功能緩慢下降（選項 B）屬於失智症（Dementia）的特徵。譫妄狀態下，定向感通常會隨時間波動，而非全天穩定。
The core features of delirium are rapid onset and fluctuating course. Clients typically exhibit difficulty maintaining attention, fluctuating level of consciousness, and acute onset. In contrast, slow, progressive cognitive decline (option B) is characteristic of dementia. In delirium, orientation also fluctuates over time and is not stable throughout the day.
✦ 台美臨床差異
美國醫院有嚴格的 Confusion Assessment Method (CAM) 篩檢；台灣則較依賴臨床醫師經驗判斷。