護理師照護一位酒精使用障礙且處於戒斷期的個案。應監測哪些徵象以評估是否出現酒精戒斷譫妄？（選所有適合的）
A nurse is caring for a client with a history of alcohol use disorder who is in withdrawal. Which symptoms should the nurse monitor for signs of delirium tremens? (Select all that apply.)
- ATachycardia✓ 正解心搏過速
- BVisual hallucinations✓ 正解幻視
- CSevere hypertension✓ 正解嚴重高血壓
- DReduced level of consciousness意識水平降低
- EDiaphoresis✓ 正解盜汗
酒精戒斷譫妄（DTs）是嚴重的急症，特徵包括交感神經風暴（心跳過快、高血壓、盜汗）以及認知障礙（幻覺）。昏迷或意識層次降低通常與其他合併症（如頭部外傷或中毒）有關，非典型 DTs 特徵。必須密切監測生命徵象以防心血管衰竭。
Delirium tremens (DTs) is a serious emergency characterized by a sympathetic storm (tachycardia, hypertension, diaphoresis) and cognitive disturbance (hallucinations). Coma or decreased level of consciousness is more often related to comorbid conditions (such as head trauma or intoxication) and is not a typical DT feature. Close monitoring of vital signs is required to prevent cardiovascular collapse.
美台皆採用 CIWA-Ar 量表監測，但台灣在處理嚴重戒斷個案時，更常採取會診精神科醫師進行藥物調整。