針對酒精戒斷症候群的個案，下列哪些護理措施是適當的？（選所有適合的）
Which of the following interventions are appropriate for a client diagnosed with alcohol withdrawal syndrome? (Select all that apply.)
- AMonitor vital signs every 4 hours每 4 小時監測生命徵象
- BMaintain a quiet, low-stimulation environment✓ 正解維持安靜、低刺激的環境
- CAdminister benzodiazepines as ordered✓ 正解依醫囑給予苯二氮平類藥物
- DOrient the client to person, place, and time frequently✓ 正解頻繁協助個案確認人、時、地之定向
- ERestrict all visitors to prevent agitation限制所有訪客以預防躁動
酒精戒斷需要密切觀察以預防嚴重併發症（如瞻妄）。環境應保持安靜、低刺激，以減緩焦慮與神經興奮；苯二氮平類藥物是戒斷症狀的首選處置；給予定向感引導能減輕精神混亂。A 選項應更為頻繁（如每 1-2 小時）觀察；E 選項過於激進，部分的支持性探視可能有助於定向感與穩定情緒。
Alcohol withdrawal requires close observation to prevent serious complications such as delirium tremens. The environment should be kept quiet and low-stimulation to ease anxiety and neuronal hyperexcitability; benzodiazepines are the first-line treatment for withdrawal symptoms; providing reality orientation can reduce mental confusion. Option A should be more frequent (such as every 1–2 hours); Option E is overly restrictive — selected supportive visits may actually help maintain orientation and emotional stability.
美國常使用 CIWA-Ar 量表管理戒斷，台灣亦有導入，但執行落實度與護理師給藥自主權在兩地有制度差異。