— 照護管理 · HARD · MCQ —
護理師為一位有酒精使用障礙的病人進行入院評估，入院初期最適當的照護目標為何？
A nurse is conducting an admission assessment on a client with a history of alcohol use disorder. Which management goal is most appropriate for the initial phase of care?
- AEnsure safety by preventing withdrawal seizures✓ 正解透過預防戒斷性癲癇來確保安全
- BIdentify the cause of alcohol dependency找出酒精依賴的原因
- CInitiate long-term rehabilitation counseling開始長期復健諮商
- DAssess the client's readiness to quit drinking評估個案戒酒的意願
— Explanation · 中文詳解 —
護理管理的首要原則是生理安全（ABC 原則的延伸）。酒精戒斷症狀可能在最後一次飲酒後 6-48 小時內發生，嚴重時伴隨癲癇發作或震顫性譫妄（DTs）。因此，入院初期的優先任務是預防生理併發症，確保病人安全。
The first principle of nursing management is physiological safety (an extension of ABC). Alcohol withdrawal symptoms can occur within 6-48 hours after the last drink, with severe cases involving seizures or delirium tremens (DTs). Therefore, the initial priority at admission is preventing physiological complications and ensuring client safety.
✦ 台美臨床差異
美台臨床對於酒精戒斷的藥物指引（如 Benzodiazepines 的使用）與護理評估（如 CIWA-Ar 量表）皆趨於標準化。