# 一位在24小時前停止大量飲酒的個案出現顫抖、盜汗、焦慮，並報告看到牆上有蟲子。護理師應預期採取哪項行動？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394130&lang=zh-tw  
> language: zh-TW  
> subject: Mental Health Concepts  
> category: PSI

## 題目

一位在24小時前停止大量飲酒的個案出現顫抖、盜汗、焦慮，並報告看到牆上有蟲子。護理師應預期採取哪項行動？

## 選項

1. 給予處方的 benzodiazepine 並維持癲癇預防措施。 **✔ 正確答案**
2. 鼓勵個案在未進一步評估的情況下入睡。
3. 提供含咖啡因的咖啡以提高警覺性。
4. 將個案安置於刺激性的團體活動中。

**正確答案: 1**

## 解析

停止大量飲酒後出現顫抖、盜汗、焦慮和幻覺，可能表示酒精戒斷，且有癲癇發作或震顫性譫妄的風險。通常會處方 benzodiazepine，並需要癲癇預防措施和密切監測。咖啡因和刺激可能會使症狀惡化。

## 深入解析

臨床判斷
酒精戒斷可能危及生命，因此早期安全性和藥物處置方案很重要。

記憶提示
戒斷：顫抖、盜汗、幻覺、癲癇。

## 臨床情境

臨床實務指引
戒斷照護包括症狀評分、生命徵象、癲癇預防措施、輸液、thiamine 和處方的鎮靜治療。

注意事項
幻覺和自主神經症狀需要立即升級處理。

## 重要概念

- **酒精戒斷** — 減少或停止大量飲酒後出現的症狀。
- **震顫性譫妄** — 一種嚴重的戒斷狀態，伴隨意識混亂、自主神經不穩定和幻覺。
- **Benzodiazepine** — 一類常用於處理酒精戒斷的鎮靜藥物。

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