護理師評估一位有酒精使用障礙史且於 48 小時前入院的病人。病人現在表現焦躁、大汗淋漓，並聲稱看到牆上有「大蜘蛛」。護理師優先採取的行動為何？
A nurse is assessing a client with a history of alcohol use disorder who was admitted 48 hours ago. The client is now agitated, sweating profusely, and reporting seeing 'giant spiders' on the walls. Which action is the priority?
- AApply physical restraints to prevent the client from falling施加身體約束以防止病人跌倒
- BInstruct the client that there are no spiders on the wall告知病人牆上沒有蜘蛛
- CTurn on all the lights in the room to improve visibility打開房間內的所有燈具以改善可見度
- DObtain a prescription for a sedative such as diazepam✓ 正解取得如地西泮等鎮靜劑的醫囑
此題考點在於識別並處置酒精戒斷性譫妄（Delirium Tremens, DTs）。病人在停酒 48-72 小時後出現幻視、自律神經亢進（流汗）與焦躁，這是醫療緊急狀況。核心概念是穩定神經系統以防止抽搐或死亡。正確答案 D 是因為 Benzodiazepines（如 Diazepam 或 Lorazepam）是治療酒精戒斷的金標準，能替代酒精對 GABA 受體的作用，降低中樞神經興奮。選項 B 試圖糾正幻覺在譫妄狀態下效果有限且可能激怒病人；選項 A 的約束是最後手段且可能增加焦慮；選項 C 雖然能減少視錯覺，但藥物控制生理徵象才是救命關鍵。臨床思路上，安全優先於所有心理支持，因為 DTs 的死亡率若不治療可高達 5-15%。
The client is exhibiting signs of alcohol withdrawal delirium, a medical emergency requiring immediate stabilization of the central nervous system. Obtaining a prescription for a benzodiazepine like diazepam is the priority intervention, as these medications are the gold standard for preventing seizures and reducing autonomic hyperactivity. While environmental modifications and reassurance are supportive, pharmacological control is essential to prevent life-threatening complications.
美國 NCLEX 考試中高度強調 CIWA-Ar 評分表的使用作為給藥依據；台灣醫院雖然也使用 CIWA，但實務上常由醫師根據臨床判斷決定劑量，護理師需更主動回報生理徵象的變動以取得醫囑。