護理師準備收治一位有酒精使用障礙史的病人。若病人正處於早期酒精戒斷階段，護理師應預期會有哪些評估發現？（選所有適合的）
A nurse is preparing to admit a client with a history of alcohol use disorder. Which assessment findings should the nurse expect if the client is experiencing early alcohol withdrawal? (Select all that apply.)
- AFine tremors of the hands✓ 正解手部細微震顫
- BTachycardia and hypertension✓ 正解心搏過速及高血壓
- CSevere visual hallucinations嚴重視幻覺
- DIrritability and anxiety✓ 正解易怒及焦慮
- EPinpoint pupils針尖樣瞳孔
酒精戒斷症狀通常在停止飲酒後 6-24 小時內開始出現（早期）。核心症狀包括中樞神經系統的過度興奮。選項 A（手抖）、選項 B（心跳過快、血壓升高）以及選項 D（焦慮、易怒）是早期的典型表現。選項 C（嚴重的視覺幻覺或震顫性譫妄 DTs）通常在戒斷 48-72 小時後才出現，不屬於「早期」。選項 E（針尖樣瞳孔）則是鴉片類藥物中毒的徵象，酒精戒斷時瞳孔通常是擴大或正常的。臨床思路上，護理師必須熟悉酒精戒斷的時間線，以便及時啟動 CIWA 評估量表並給予預防性藥物（如 BZD），防止惡化為癲癇或譫妄。
Alcohol withdrawal symptoms generally appear within 6–24 hours after cessation of drinking (early stage). The hallmark manifestations involve central nervous system hyperactivity. Option A (hand tremors), Option B (tachycardia and hypertension), and Option D (anxiety and irritability) are typical early findings. Option C (severe visual hallucinations or delirium tremens) usually emerges 48–72 hours after cessation and is not part of the 'early' phase. Option E (pinpoint pupils) is characteristic of opioid intoxication; in alcohol withdrawal, pupils are typically dilated or normal. Clinically, the nurse must be familiar with the timeline of alcohol withdrawal to promptly initiate CIWA scoring and administer prophylactic medications (such as benzodiazepines) to prevent progression to seizures or delirium.
在美國，CIWA-Ar 量表是酒精戒斷護理的標準化工具，護理師根據評分自主決定 PRN 藥物劑量；台灣臨床雖也使用量表，但給藥通常仍需逐次聯繫醫師確認，護理師的自主權相對較小。