— 心理社會完整性 · HARD · MCQ —
一位酒精使用障礙病人因戒斷症狀入院。哪項評估發現需要立即護理介入？
A client with alcohol use disorder is admitted for detoxification. Which assessment finding requires immediate nursing intervention?
- ABlood pressure 150/95 mmHg血壓 150/95 mmHg
- BHallucinations and confusion✓ 正解幻覺和意識混亂
- CHand tremors手部震顫
- DDiaphoresis盜汗
— Explanation · 中文詳解 —
酒精戒斷譫妄（Delirium Tremens）是嚴重的戒斷症狀，特徵為定向感障礙、幻覺及意識混亂。若不處理，可導致抽搐及生命體徵不穩，危及生命。其他選項雖為戒斷症狀，但 B 代表病情進入譫妄階段，風險最高。
Delirium tremens is a severe alcohol withdrawal syndrome characterized by disorientation, hallucinations, and confusion. Without treatment, it can lead to seizures and vital sign instability and be life-threatening. The other options are also withdrawal symptoms, but B indicates that the condition has progressed to the delirium stage and carries the highest risk.
✦ 台美臨床差異
美台均對酒精戒斷採取 CIWA-Ar 量表監測，台灣臨床對戒斷藥物使用較為保守。