— 心理社會完整性 · MEDIUM · SATA —
護理師為酒精戒斷個案規劃照護內容，應包含下列哪些項目？（選所有適合的）
Which of the following interventions should a nurse include in the plan of care for a client experiencing alcohol withdrawal? (Select all that apply.)
- AMonitor vital signs every 2-4 hours✓ 正解每 2-4 小時監測生命徵象
- BAdminister benzodiazepines as ordered✓ 正解依醫囑給予苯二氮平類藥物
- CEnsure a quiet, dimly lit environment✓ 正解確保安靜、光線昏暗的環境
- DRestrict all visitors to prevent agitation限制所有探視以預防躁動
- EAssess for tremors, diaphoresis, and hallucinations✓ 正解評估是否有顫抖、盜汗和幻覺
— Explanation · 中文詳解 —
酒精戒斷症候群可能導致震顫譫妄，需嚴密監測生命徵象與神經系統變化。給予苯二氮平類藥物可降低戒斷症狀；環境應維持光線柔和、降低聲音刺激以防驚嚇。不應全面限制所有訪客，適度支持有助於穩定情緒，D 選項過於絕對。
Alcohol withdrawal management includes monitoring vital signs for autonomic hyperactivity and administering benzodiazepines as prescribed. A quiet, low-stimulation environment helps prevent sensory overload, while moderate social support is beneficial.
✦ 台美臨床差異
美籍護理師多使用 CIWA-Ar 量表評估；台灣臨床亦逐漸引進，但依賴臨床經驗判斷較多。