護理師正在照顧一位正在戒斷酒精的病人。護理師應監測下列哪項臨床表現，因為它是戒斷過程中最嚴重的併發症？
A nurse is caring for a client who is undergoing alcohol withdrawal. Which clinical manifestation should the nurse monitor for as the most serious complication of withdrawal?
- ADiaphoresis and tachycardia盜汗與心搏過速
- BVisual hallucinations視幻覺
- CDelirium tremens (DTs)✓ 正解震顫性譫妄（DTs）
- DFine tremors of the hands手指細微震顫
酒精戒斷的症狀從輕微到致命不等。核心概念是識別『致命併發症』。選項 C（震顫性譫妄，DTs）是酒精戒斷最嚴重的形式，通常發生在停止飲酒後 48-72 小時。其特徵包括嚴重的意識模糊、震顫、幻覺、高血壓、心搏過速甚至死亡。選項 D（細微震顫）是早期且常見的症狀；選項 A（出汗與心搏過速）屬於自主神經亢進，雖然需要處理，但危險程度不及 DTs；選項 B（視幻覺）可能單獨出現（酒精幻覺症），若伴隨意識喪失與全身症狀則屬於 DTs 的一部分。護理重點在於早期識別 CIWA 評分上升並及時給予 Benzodiazepines。
Symptoms of alcohol withdrawal range from mild to potentially fatal. The core concept is to identify the 'fatal complication.' Option C, delirium tremens (DTs), is the most severe form of alcohol withdrawal and typically occurs 48-72 hours after cessation of drinking. Features include severe confusion, tremors, hallucinations, hypertension, tachycardia, and even death. Option D (fine tremors) is an early, common symptom; option A (diaphoresis and tachycardia) represents autonomic hyperactivity, which requires treatment but is less dangerous than DTs; option B (visual hallucinations) may occur alone (alcoholic hallucinosis), but combined with altered consciousness and systemic symptoms it forms part of DTs. Nursing emphasis is on early identification of a rising CIWA score and timely administration of benzodiazepines.
美國臨床廣泛使用 CIWA-Ar 量表來標準化酒精戒斷的評估與用藥；台灣雖然也有醫院使用，但在某些基層病房，仍較依賴醫師的臨床經驗判斷給藥。NCLEX 非常強調 CIWA 評估與 DTs 的預防。