— 心理社會完整性 · MEDIUM · MCQ —
一位 45 歲酒精使用障礙病患入院進行戒斷。入院後 24 小時內，護理師應優先評估下列哪項臨床表現？
A 45-year-old client with a history of alcohol use disorder is admitted for detoxification. Which assessment finding should the nurse prioritize during the first 24 hours?
- AFine tremors of the hands手部細微震顫
- BVisual hallucinations視覺幻覺
- CDiaphoresis and hypertension✓ 正解盜汗和高血壓
- DNausea and vomiting噁心和嘔吐
— Explanation · 中文詳解 —
酒精戒斷症候群在初期可能出現交感神經過度興奮，如盜汗、高血壓及心跳過速，這是引發癲癇發作及譫妄的前兆。雖然幻覺與噁心也很常見，但生命徵象的劇烈變化直接威脅生命安全，需優先處理以防演變成酒精戒斷譫妄 (DTs)。
In the early stages of alcohol withdrawal syndrome, sympathetic overactivity may occur, presenting as diaphoresis, hypertension, and tachycardia, which are precursors to seizures and delirium. Although hallucinations and nausea are also common, dramatic changes in vital signs pose a direct threat to life and must be addressed first to prevent progression to delirium tremens (DTs).
✦ 台美臨床差異
美國常使用 CIWA-Ar 量表進行結構化評估，台灣則較多依賴醫囑或常規生命徵象紀錄。