— 降低風險 · EASY · MCQ —
護理師評估一位深部靜脈栓塞（DVT）的病人，哪項是典型的臨床症狀？
A nurse is assessing a client for signs of deep vein thrombosis (DVT). Which finding is a classic clinical manifestation?
- APallor of the limb with absence of pulses肢體蒼白且無脈搏
- BUnilateral leg swelling and calf pain✓ 正解單側腿部水腫與小腿疼痛
- CRedness and warmth over the entire foot整個腳掌紅腫發熱
- DBilateral pedal edema with cold extremities雙側足部水腫伴隨四肢冰冷
— Explanation · 中文詳解 —
DVT 的典型表現為患側肢體單側水腫、發熱及壓痛（Homan's sign 雖不具特異性，但局部壓痛明顯）。B 為心衰竭或周邊血管問題；C 為動脈栓塞表現；D 紅熱多見於蜂窩性組織炎，若為 DVT 通常僅限於靜脈路徑區域。
DVT classically presents with unilateral limb swelling, warmth, and tenderness (Homan's sign is nonspecific, but localized tenderness is prominent). Option D suggests heart failure or peripheral vascular disease; option A suggests arterial occlusion; option C, with generalized redness and warmth, is more typical of cellulitis. In DVT the inflammation is usually confined to the affected venous distribution.
✦ 台美臨床差異
兩地均強調避免過度按壓患肢以免造成栓子脫落，但在臨床評估工具（如 Wells score）的使用上美國護理師更為普及。