一位戒酒中的病人出現顫抖、盜汗與心搏過速。哪些護理措施是適當的？（選所有適合的）
A client recovering from alcohol withdrawal exhibits tremors, diaphoresis, and tachycardia. Which nursing interventions are appropriate? (Select all that apply.)
- AMonitor vital signs every 15 to 30 minutes✓ 正解每 15 至 30 分鐘監測生命徵象
- BMaintain a low-stimulus environment✓ 正解維持低刺激環境
- CRestrict all fluid intake to prevent aspiration限制所有液體攝取以防吸入性肺炎
- DAssess orientation frequently✓ 正解經常評估定向力
- EAdminister benzodiazepines as ordered✓ 正解依醫囑給予苯二氮平類藥物
戒酒症候群病人需密切監測生命徵象以防癲癇或譫妄發生。低刺激環境能降低焦慮與混亂。意識評估可及早發現認知功能變化。苯二氮平類藥物為治療戒斷症狀的第一線藥物。限制所有水分攝取是錯誤的，病人因盜汗可能脫水，應根據醫囑給予液體補充。
Clients withdrawing from alcohol require close monitoring of vital signs to detect seizures or delirium. A low-stimulus environment reduces anxiety and confusion. Frequent orientation assessment helps detect cognitive changes early. Benzodiazepines are the first-line treatment for withdrawal symptoms. Restricting all fluid intake is incorrect, as clients are at risk for dehydration from diaphoresis; fluids should be provided per the provider's order.
美國常使用 CIWA-Ar 量表指導藥物給予；台灣臨床則較多依賴醫師依據經驗與體徵給予固定處方。