一位 45 歲酒精使用障礙個案因戒斷進行住院排毒。下列哪項評估結果需要護理師立即通知醫師？
A 45-year-old client with alcohol use disorder is admitted for detoxification. Which assessment finding requires the nurse to notify the provider immediately?
- AAuditory hallucinations and disorientation✓ 正解聽覺幻覺與定向力障礙
- BNausea and irritability噁心與易怒
- CMild hand tremors輕微手部震顫
- DInsomnia and anxiety失眠與焦慮
酒精戒斷譫妄（Delirium Tremens）是嚴重的醫療急症，症狀包括幻覺、意識混亂、震顫及生命徵象不穩。選項 C、B、D 皆為戒斷初期的常見症狀，雖需監測但非立即危急；幻覺與意識混亂提示進入譫妄階段，有致命風險，需立即醫療干預。
Delirium tremens is a serious medical emergency, with symptoms including hallucinations, disorientation, tremors, and unstable vital signs. Options C, B, and D are common findings in early withdrawal—they require monitoring but are not immediately life-threatening. Hallucinations and disorientation indicate progression into the delirium stage, which carries a risk of death and requires immediate medical intervention.
美國酒精戒斷多有結構化臨床量表（CIWA-Ar）執行；台灣臨床則多由資深護理師臨床判斷，並隨時回報給精神科或內科醫師。