一位病人因酒精戒斷入院。護理師應監測哪些酒精戒斷的早期症狀？（選所有適合的）
A client is admitted for alcohol detoxification. Which symptoms should the nurse monitor for as early signs of alcohol withdrawal? (Select all that apply.)
- AFine tremors of the hands✓ 正解手部細微震顫
- BNausea and vomiting✓ 正解噁心與嘔吐
- CBradycardia and hypotension心動過緩與低血壓
- DAnxiety and irritability✓ 正解焦慮與易怒
- EVisual or tactile hallucinations視覺或觸覺幻覺
酒精戒斷症狀通常在停止飲酒後的 6-24 小時內開始出現。早期（輕度）症狀主要源於中樞神經系統的過度興奮。選項 A（手抖）、選項 B（噁心嘔吐）及選項 D（焦慮易怒）都是典型的早期警訊。選項 C 是錯誤的，戒斷反應會導致交感神經亢進，因此應該是心搏過速（Tachycardia）與血壓升高。選項 E（幻覺）通常出現在戒斷後的 12-48 小時，雖然也算早期，但相對於手抖和焦慮，它更趨向於中度戒斷，且並非所有病人都會出現。臨床思路上，護理師必須熟悉戒斷的時間軸，以便及時給予苯二氮平類藥物（Benzodiazepines）來預防嚴重的震顫性譫妄（Delirium Tremens）。預防性用藥的關鍵在於捕捉這些早期的神經興奮體徵。
Alcohol withdrawal symptoms typically begin within 6 to 24 hours after the last drink. Early (mild) symptoms primarily arise from central nervous system hyperexcitability. Option A (hand tremors), option B (nausea and vomiting), and option D (anxiety and irritability) are all typical early warning signs. Option C is incorrect, because withdrawal causes sympathetic hyperactivity and would therefore produce tachycardia and hypertension. Option E (hallucinations) usually appears 12 to 48 hours after cessation; although still relatively early, it is more characteristic of moderate withdrawal and does not occur in all patients. Clinically, the nurse must be familiar with the timeline of withdrawal in order to administer benzodiazepines in time to prevent severe delirium tremens. The key to prophylactic medication is recognizing these early signs of neurologic excitation.
美國醫院普遍使用 CIWA-Ar 量表來結構化評估戒斷程度並導引藥物給予；台灣臨床雖然也會評估，但較常依賴醫師的主觀判斷或護理紀錄描述，較少全面性地推廣標準化量表進行 PRN 給藥指導。