# 一名住院病人距上次飲酒已18小時，出現震顫、出汗，並報告有視幻覺。哪項護理措施最適當？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397291&lang=zh-tw  
> language: zh-TW  
> subject: Mental Health Concepts  
> category: PSI

## 題目

一名住院病人距上次飲酒已18小時，出現震顫、出汗，並報告有視幻覺。哪項護理措施最適當？

## 選項

1. 依醫囑啟動戒斷治療方案及癲癇預防措施。 **✔ 正確答案**
2. 鼓勵個案獨自散步以減少躁動。
3. 解釋幻覺表示個案並非真正在戒斷。
4. 暫停給予處方的 benzodiazepines 直到個案睡著。

**正確答案: 1**

## 解析

震顫、出汗與幻覺表示明顯的酒精戒斷，有癲癇發作或譫妄顫動的風險。護理人員應啟動醫囑的戒斷治療方案與安全預防措施。單獨行走或停用適應症藥物可能增加傷害。

## 深入解析

臨床判斷
使用個案線索、時機、檢驗數據及安全風險，選擇最符合酒精戒斷安全的回應。

記憶提示
將最強的線索群與最安全的護理判斷配對。

KR vs US
NCLEX 題目獎勵基於線索的優先思考，而非單獨的記憶。

## 臨床情境

臨床實務指引
對於酒精戒斷安全，將完整的線索模式與個案當前的穩定性、醫囑數據及預期的護理範圍進行比較。

注意
當完整情境改變了優先順序或安全性時，不要僅根據單一線索選擇行動。

## 重要概念

- **酒精戒斷** — 停止或減少大量飲酒後可能發生的症候群。
- **癲癇預防措施** — 用於有癲癇發作風險個案的安全措施。
- **震顫性譫妄** — 一種嚴重的酒精戒斷形式，伴隨意識混亂、自律神經不穩定及幻覺。

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