— 心理社會完整性 · HARD · SATA —
一位 30 歲女性因酒精戒斷入院。護理師應預期出現哪些症狀？（選所有適合的）
A 30-year-old woman is admitted for alcohol withdrawal. Which of the following should the nurse anticipate? (Select all that apply.)
- ATremors and diaphoresis✓ 正解顫抖與盜汗
- BAuditory or visual hallucinations✓ 正解聽覺或視覺幻覺
- CIncreased blood pressure and pulse✓ 正解血壓與脈搏增加
- DProfound lethargy and slowed heart rate極度嗜睡與心率減慢
- ESeizures✓ 正解癲癇發作
— Explanation · 中文詳解 —
酒精戒斷表現為中樞神經系統過度興奮（Hyper-excitability）。常見症狀有顫抖、盜汗、心搏過速、高血壓、幻覺，嚴重者甚至會出現癲癇（Seizures）與震顫譫妄。昏睡（D）與心率減慢通常是鴉片類或鎮靜藥物中毒的特徵，非酒精戒斷表徵。
Alcohol withdrawal causes central nervous system hyperexcitability, leading to autonomic instability such as tremors, diaphoresis, hypertension, and tachycardia. Clients may also experience sensory disturbances like auditory or visual hallucinations. In severe cases, this hyperactivity can progress to seizures. Lethargy and bradycardia are signs of CNS depression, typically associated with substance intoxication rather than withdrawal.
✦ 台美臨床差異
美國常使用 CIWA-Ar 量表進行戒斷監測；台灣臨床亦多採此量表，但護理師執行細節需與醫師密切同步。