— 心理社會完整性 · HARD · MCQ —
護理師照護一位酒精戒斷症候群的病人。下列哪項評估結果最令人擔憂？
A nurse is caring for a client with alcohol withdrawal syndrome. Which assessment finding is most concerning?
- AAuditory and visual hallucinations✓ 正解聽覺與視覺幻覺
- BTachycardia and hypertension心搏過速與高血壓
- CMild irritability輕度易怒
- DHand tremors手部顫抖
— Explanation · 中文詳解 —
酒精戒斷嚴重度分為幾級。幻覺（hallucinations）顯示戒斷已進展至酒精戒斷性譫妄（Delirium Tremens, DTs）的前兆，這是危及生命的急症，較單純的震顫或輕度生命徵象改變風險更高。需立即監控與給藥。
Auditory and visual hallucinations are the most concerning finding as they indicate the potential onset of delirium tremens, a life-threatening complication of alcohol withdrawal. While tremors and autonomic instability are common, hallucinations signal a severe progression requiring immediate intervention.
✦ 台美臨床差異
美國採用 CIWA-Ar 量表進行常規監測並依分數給藥；台灣部分醫院依醫師固定醫囑給藥，依量表調整劑量者較少。