— 心理社會完整性 · HARD · MCQ —
針對急性酒精戒斷入院的個案，下列哪項護理介入優先級最高？
Which of the following interventions is highest priority for a client admitted with acute alcohol withdrawal?
- AMaintaining a quiet, dimly lit environment維持安靜、光線昏暗的環境
- BAdministering IV vitamins給予靜脈注射維生素
- CMonitoring for seizures and vital sign instability✓ 正解監測癲癇發作與生命徵象不穩定
- DEncouraging group therapy participation鼓勵參與團體治療
— Explanation · 中文詳解 —
酒精戒斷涉及生命危險（如震顫譫妄、癲癇）。監測生命徵象與神經系統狀態以預防癲癇發作是護理優先任務。維生素補充（B）雖重要，但屬次要任務；環境安靜（A）是協助舒適，非優先救命；小組治療（D）在急性期個案病情尚未穩定前並不適用。
The highest priority for a client with acute alcohol withdrawal is monitoring for seizures and vital sign instability, as these conditions can be life-threatening. While environmental modifications and vitamin supplementation are part of comprehensive care, ensuring physiological stability and preventing neurological complications take precedence. Group therapy is inappropriate during the acute phase when the client is medically unstable.
✦ 台美臨床差異
美方多使用 CIWA-Ar 量表進行結構化評估，台灣則視臨床習慣與醫療院所規範而定。