— 心理社會完整性 · HARD · MCQ —
一位酒精使用障礙病史的病人因戒斷入院。下列何種評估發現需要護理師立即介入？
A patient with a history of alcohol use disorder is admitted for detoxification. Which assessment finding requires immediate nursing intervention?
- ADiaphoresis and tachycardia盜汗和心搏過速
- BHand tremors手部震顫
- CMild irritability輕度煩躁不安
- DVisual hallucinations and confusion✓ 正解視覺幻覺和意識混亂
— Explanation · 中文詳解 —
酒精戒斷譫妄（Delirium Tremens）是危險的戒斷後期症狀，通常在戒斷後 48-72 小時出現。出現視覺幻覺與意識混亂代表已進入譫妄狀態，病人的安全風險極高，需立即給予抗焦慮藥物或安置於安全環境，並通知醫師。
Delirium tremens (DTs) is a dangerous late-stage manifestation of alcohol withdrawal, typically appearing 48–72 hours after cessation. The onset of visual hallucinations and confusion indicates that the patient has progressed into a delirious state, posing an extremely high safety risk. Immediate administration of an anxiolytic, placement in a safe environment, and notification of the physician are required.
✦ 台美臨床差異
美國多使用 CIWA 評分表標準化監測；台灣臨床則多依賴資深護理師經驗，標準化監測工具應用率較低。