— 降低風險 · HARD · MCQ —
護理師照護一位有深部靜脈栓塞病史的病人，下列哪項評估發現最令人擔心？
A nurse is caring for a client with a history of deep vein thrombosis (DVT). Which assessment finding is most concerning?
- AParesthesia in the affected extremity患肢感覺異常
- BErythema and warmth in the left calf左小腿紅腫發熱
- CSudden onset of sharp chest pain and dyspnea✓ 正解突然發作的劇烈胸痛和呼吸困難
- DTrace edema in the bilateral ankles雙踝輕微水腫
— Explanation · 中文詳解 —
深部靜脈栓塞（DVT）最危險的併發症是肺栓塞（PE）。突發性的胸痛與呼吸困難是 PE 的典型症狀，屬於立即威脅生命的緊急狀況。小腿紅腫熱是 DVT 本身的症狀，需處理但不如 PE 致命。水腫需評估，感覺異常需檢查，但皆非優先順序。
The most dangerous complication of deep vein thrombosis (DVT) is pulmonary embolism (PE). Sudden chest pain and dyspnea are classic symptoms of PE and represent an immediately life-threatening emergency. Redness, swelling, and warmth in the calf are symptoms of the DVT itself; they require intervention but are not as lethal as PE. Edema requires evaluation, and paresthesia warrants examination, but neither is the priority.
✦ 台美臨床差異
美台皆強調 PE 的高致命率。台灣醫師常要求護理師若懷疑 PE 立即啟動 Code Blue 或呼叫醫師評估。