一位病人突然變得意識模糊且躁動，護理師應採取哪些措施？（選所有適合的）
A nurse is caring for a client who suddenly becomes confused and restless. Which interventions should the nurse perform? (Select all that apply.)
- ACheck oxygen saturation✓ 正解檢查血氧飽和度
- BAssess blood glucose level✓ 正解評估血糖水平
- CCall the family to discuss discharge聯絡家屬討論出院事宜
- DCheck vital signs✓ 正解檢查生命徵象
- EAssess neurological status✓ 正解評估神經狀態
急性意識混亂與躁動通常是生理功能失調的警訊。護理師應採用 ABC（Airway, Breathing, Circulation）思路，優先評估血氧狀況（缺氧常導致意識改變）與生命徵象；血糖異常（低血糖或高血糖滲透壓）也是常見原因；神經學檢查則用於排除腦血管意外。這些評估有助於釐清病因以進行針對性處理。
Acute confusion and restlessness are usually warning signs of physiological dysfunction. The nurse should follow the ABC (Airway, Breathing, Circulation) approach and prioritize assessment of oxygen saturation (since hypoxia commonly causes mental status changes) and vital signs; abnormal blood glucose (hypoglycemia or hyperglycemic hyperosmolar state) is also a common cause; and neurologic examination is used to rule out cerebrovascular events. These assessments help identify the cause and guide targeted management.