一位病人因酒精戒斷入院，護理師在入院 24 小時內應優先監測何種評估結果？
A client is admitted for alcohol withdrawal. Which assessment finding should the nurse prioritize during the first 24 hours of admission?
- AFine hand tremors細微的手顫抖
- BAuditory hallucinations聽覺幻覺
- CElevated blood pressure and pulse✓ 正解血壓升高與脈搏加快
- DMild irritability and anxiety輕度易怒與焦慮
酒精戒斷的生理反應多樣，其中以心血管系統的不穩定最具生命威脅。血壓與心跳顯著上升是自主神經系統過度興奮的徵兆，預示著可能發生震顫譫妄（Delirium Tremens）或癲癇發作。其他選項如震顫、焦慮或幻覺雖然是戒斷症狀，但在優先級上，穩定血流動力學以預防心血管併發症最為關鍵。
The physiological responses of alcohol withdrawal are varied, but instability of the cardiovascular system poses the greatest threat to life. A significant rise in blood pressure and pulse is a sign of autonomic hyperactivity and may herald the onset of delirium tremens or seizures. Although tremor, anxiety, and hallucinations are also withdrawal symptoms, the highest priority is stabilizing hemodynamics in order to prevent cardiovascular complications.
美台臨床皆採用 CIWA-Ar 量表監測，但台灣護理師在觀察到數據異常時，需更頻繁確認醫囑中的 PRN 鎮靜藥物使用。