護理師針對酒精戒斷期的病人，下列哪些評估最為關鍵？（選所有適合的）
Which of the following assessments would be most important for the nurse to perform for a client experiencing the withdrawal phase of alcohol dependence? (Select all that apply.)
- AMonitoring vital signs for hypertension and tachycardia✓ 正解監測生命徵象以評估是否有高血壓及心搏過速
- BAssessing for the presence of visual or tactile hallucinations✓ 正解評估是否有視覺或觸覺幻覺
- CEvaluating the client's level of orientation to time, place, and person✓ 正解評估病人對時間、地點及人物的定向力
- DMonitoring for the onset of tremors or diaphoresis✓ 正解監測是否有震顫或盜汗發生
- EAssessing the client's spiritual beliefs regarding substance use評估病人關於物質濫用的靈性信念
酒精戒斷（Delirium Tremens, DTs）可能威脅生命，重點在於監測生命徵象（血壓心跳上升）、評估認知狀態（定向力喪失）、檢測交感神經亢進症狀（盜汗、震顫）及精神症狀（幻覺）。E 選項雖重要，但對於戒斷急性期的生理穩定而言，非優先評估項目。
Alcohol withdrawal (Delirium Tremens, DTs) can be life-threatening, and the focus is on monitoring vital signs (elevated blood pressure and heart rate), assessing cognitive status (disorientation), detecting symptoms of sympathetic hyperactivity (diaphoresis, tremors), and identifying psychiatric symptoms (hallucinations). Although option E is also important, it is not a priority assessment during the acute withdrawal phase, where physiological stabilization takes precedence.
美國醫院常見使用 CIWA-Ar 量表嚴格監控；台灣則多依據醫師臨床判斷，較少使用標準化量表進行量化評估。