下列哪些評估發現符合深層靜脈栓塞（DVT）的診斷？（選所有適合的）
Which assessment findings are consistent with a diagnosis of deep vein thrombosis (DVT)? (Select all that apply.)
- AUnilateral edema of the affected limb✓ 正解患肢單側水腫
- BDiminished pedal pulses in the affected leg患側足背脈搏減弱
- CWarmth and redness over the calf area✓ 正解小腿區域發熱和紅斑
- DCalf pain or tenderness upon palpation✓ 正解小腿疼痛或觸壓痛
- ECyanosis and cool skin of the extremity肢端發紺和皮膚冰冷
深層靜脈栓塞（DVT）通常發生在下肢，由於血栓阻塞靜脈回流，會引起局部的發炎反應與液體淤積。典型症狀包括：1. 單側水腫（A），兩腿周徑差異大於 3 公分具臨床意義；2. 局部發熱與發紅（C），這是靜脈淤滯與發炎的表現；3. 壓痛（D），特別是在腓腸肌區域。選項 B（脈搏減弱）與 E（皮膚蒼白濕冷或發紺）則是「動脈」阻塞（如急性動脈栓塞）的特徵。在靜脈栓塞中，動脈血流通常是正常的，因此脈搏應可觸及。護理師必須區分動脈與靜脈循環問題的差異，這對採取正確的介入（如靜脈血栓需臥床避免脫落，動脈血流不足需避免壓迫）至關重要。現在臨床已不建議常規執行 Homans' sign（強烈背屈足部看是否疼痛），因為其敏感度低且可能導致血栓脫落。
Deep vein thrombosis (DVT) typically occurs in the lower extremities; obstruction of venous return by the thrombus causes a localized inflammatory response and fluid stasis. Typical findings include: 1. Unilateral edema (A), with a circumference difference of greater than 3 cm between the two legs being clinically significant; 2. Local warmth and redness (C), reflecting venous stasis and inflammation; 3. Tenderness (D), particularly in the calf muscle area. Options B (diminished pulses) and E (pallor with cool, clammy skin or cyanosis) are features of arterial occlusion (such as acute arterial embolism). In venous thrombosis, arterial flow is typically normal, so pulses should remain palpable. The nurse must distinguish arterial from venous circulation problems, which is crucial for selecting the correct interventions (for example, bed rest is used in venous thrombosis to prevent dislodgement, while compression should be avoided in arterial insufficiency). Routine performance of Homans' sign (forceful dorsiflexion of the foot to elicit pain) is no longer recommended clinically because of its low sensitivity and potential to dislodge a clot.
美國 NCLEX 考試已將 Homans' sign 視為過時且潛在危險的評估動作。台灣部分教科書與臨床前輩可能仍會提及，但現代護理實務皆強調以超音波（Duplex Ultrasound）與 D-dimer 作為標準。兩地皆極度強調預防（如使用 SCDs、早期下床）。