病人主訴右小腿疼痛且走路時加劇。哪項評估結果最令護理師擔憂？
A client complains of pain in the right calf that worsens when walking. Which assessment finding is most concerning to the nurse?
- ABilateral pedal pulses of +2 intensity雙側足背動脈搏動強度為+2
- BA warm, erythematous, and swollen calf✓ 正解小腿紅腫且觸感溫暖
- CA cool, pale lower leg下肢冰冷蒼白
- DA superficial vein visible near the ankle踝關節附近可見淺層靜脈
此題需區分動脈與靜脈疾病的緊急度。選項 C 為慢性動脈阻塞現象，雖需注意但不一定有即刻生命危險；選項 B 指向深部靜脈栓塞（DVT），紅、腫、熱、痛為經典症狀，最大的危險在於栓子脫落引發肺栓塞（PE），此為危及生命的急症，故優先處理。
This question requires differentiating the urgency of arterial versus venous disease. Option C represents a chronic arterial occlusion finding that, while requiring attention, is not necessarily immediately life-threatening. Option B is suggestive of deep vein thrombosis (DVT), with redness, swelling, warmth, and pain as classic symptoms. The greatest danger is dislodgement of the thrombus leading to pulmonary embolism (PE), which is a life-threatening emergency and therefore takes priority.
台灣臨床非常重視 DVT 的風險評估（如 Wells score），護理師需警覺此症狀並立即啟動預防栓子脫落的護理計畫。