一位45歲男性因車禍導致股骨骨折而入院。個案入院時並未完全揭露其過往病史。在入院第 3 天（約入院後72小時），個案突然變得極度焦躁、大量冒汗，並展現出嚴重的全身性粗大震顫。他在床上劇烈扭動並尖叫：「妳看不到嗎？！有成千上萬的蜘蛛爬滿了我的腿在咬我！」其生命徵象瞬間飆升至血壓 170/105 mmHg，心跳 135次/分，體溫 38.6°C。針對這個特定的症候群，護理師應預期準備執行哪些緊急介入？（多選題）
A 45-year-old male is admitted for a fractured femur following a motor vehicle collision. The client's medical history was not fully disclosed upon admission. On day 3 (approximately 72 hours post-admission), the client becomes profoundly agitated, profusely diaphoretic, and exhibits severe whole-body coarse tremors. He thrashes around the bed screaming, "Can't you see them?! There are thousands of spiders crawling all over my legs biting me!" Vital signs rocket to BP 170/105 mmHg, HR 135 bpm, and Temp 38.6°C (101.5°F). Which urgent interventions should the nurse anticipate implementing for this specific syndrome? (Select all that apply.)
- AAdminister prescribed intravenous Benzodiazepines (e.g., lorazepam or diazepam) aggressively to depress the central nervous system.✓ 正解積極給予處方之靜脈注射苯二氮平類藥物（例如：勞拉西泮或地西泮）以抑制中樞神經系統。
- BDarken the room completely and isolate the client to minimize terrifying visual stimuli.將房間完全調暗並隔離個案，以最小化令人恐懼的視覺刺激。
- CInitiate strict seizure precautions, including ensuring suction and oxygen are immediately available at the bedside.✓ 正解啟動嚴格癲癇發作預防措施，包括確保抽吸裝置與氧氣立即備妥於床邊。
- DApply warm blankets extensively to manage the severe diaphoresis and induce a drop in core temperature.廣泛使用保暖毯以管理嚴重出汗並促使核心體溫下降。
- EMonitor the client's vital signs and neurological status continuously due to the high risk of fatal cardiovascular collapse.✓ 正解持續監測個案的生命徵象與神經狀態，因為有極高的致命性心血管衰竭風險。
本題測驗酒精戒斷症候群（Alcohol Withdrawal Syndrome）中最嚴重致命的階段：震顫性譫妄（Delirium Tremens, DTs）。該名病患極有可能患有嚴重的慢性隱藏性酗酒史。在被迫中斷飲酒後的 48-72 小時內爆發了典型的 DTs 症狀，包含：嚴重的自主神經亢進交感風暴（血壓與心跳狂飆）、粗大震顫（Tremors）以及幻視加觸覺幻覺（Tactile hallucinations，強烈感覺有蟲爬蟲咬，俗稱蟻走感 Formication）。這是一種隨時會致死的醫療急症。護理重點在於緊急給予中樞神經鎮靜。首選藥物為靜脈注射的苯二氮平類藥物（Benzodiazepines 如 Lorazepam），藉此取代酒精在大腦受體的作用以壓制交感風暴（選項A正確）。患者處於極端高度的癲癇誘發邊緣，必須立刻啟動防癲癇急救準備（選項C正確）。由於血壓與心跳飆升，若不及時控制，病患會死於心肌梗塞或心血管衰竭，因此必須密切追蹤（選項E正確）。選項B錯誤，完全黑暗的房間會在視覺剝奪下引發更慘烈的暗影幻覺與恐怖聯想，應保持柔和的照明。選項D錯誤，病患發高燒 38.6°C且有自主神經風暴，不應再覆蓋大量溫暖毯子以免阻礙散熱並誘發熱衰竭。
Benzodiazepines are the first-line treatment for delirium tremens to stabilize the central nervous system and suppress autonomic hyperactivity. Seizure precautions are critical because uncontrolled withdrawal can lead to life-threatening grand mal seizures. Continuous monitoring of vital signs is necessary to detect cardiovascular collapse, whereas complete darkness and excessive warming can exacerbate hallucinations and hyperthermia.
世界通用急診指標。在台美急診與骨科病房，因車禍收治但未告知酗酒史的病人，在住院第三天發狂並看見到處都是蟲的「Delirium Tremens」橋段，是臨床上幾乎每個病房護理師都經歷過的標準突發事件。