護理師評估一位 48 小時前入院、有酒精使用障礙病史的病人。病人目前表現躁動、大汗淋漓，並聲稱看到「牆壁上有蟲在爬」。下列哪項處理措施最為適當？
A nurse is assessing a client with a history of alcohol use disorder who was admitted 48 hours ago. The client is now agitated, diaphoretic, and reports seeing 'bugs crawling on the walls.' Which action is most appropriate?
- AReorient the client to the room and tell them there are no bugs將病人重新導向至房間現實，並告訴他牆上沒有蟲
- BRequest a consult for a psychiatric evaluation for schizophrenia請求精神科會診以評估思覺失調症
- CCheck the client's blood glucose level immediately立即測量病人的血糖
- DPrepare to administer diazepam as per the facility's withdrawal protocol✓ 正解準備依照機構的戒斷協議給予地西泮（diazepam）
該病人正處於酒精戒斷最嚴重的階段：酒精戒斷譫妄（Delirium Tremens, DTs），典型症狀包括入院後 48-72 小時出現的意識障礙、視幻覺（牆上有蟲）、自主神經亢進（大汗、躁動）。這是精神科急症，死亡率可達 5%。首要處置是依據戒斷標準流程（如 CIWA-Ar）給予苯二氮平類藥物（Benzodiazepines, 如 diazepam 或 lorazepam），以替代酒精對 GABA 受體的作用，預防抽搐與循環衰竭。告知病人沒有蟲（Option A）對幻覺中的譫妄病人效果有限，且可能導致其更加焦慮。低血糖（Option C）雖然也會造成神智不清，但病史與臨床表徵更強烈指向酒精戒斷。這不是思覺失調症（Option B），而是物質引起的精神病態。
The client is in the most severe stage of alcohol withdrawal: delirium tremens (DTs). Typical symptoms appear 48-72 hours after admission and include altered consciousness, visual hallucinations (such as bugs on the wall), and autonomic hyperactivity (diaphoresis, agitation). DTs is a psychiatric emergency with mortality up to 5%. The priority intervention is to administer a benzodiazepine (for example, diazepam or lorazepam) according to a standardized withdrawal protocol such as CIWA-Ar, to replace the action of alcohol on the GABA receptor and prevent seizures and circulatory collapse. Telling the delirious client that there are no bugs (Option A) is largely ineffective and may increase anxiety. Hypoglycemia (Option C) can also cause confusion, but the history and clinical picture point strongly toward alcohol withdrawal. This is not schizophrenia (Option B); it is a substance-induced psychiatric disturbance.
美國 NCLEX 非常強調 CIWA-Ar 評分表的使用，護理師根據評分高低有權限調整藥物劑量；台灣則多由醫師開立 PRN 醫囑，護理師觀察後通知醫師給藥，且臨床上常併用大量的點滴補充維生素 B1（Thiamine）。