— 降低風險 · MEDIUM · SATA —
護理師照護一位疑似深層靜脈栓塞（DVT）的病人。下列哪些評估發現符合此診斷？（選所有適合的）
A nurse is caring for a client with a suspected deep vein thrombosis (DVT). Which assessment findings are consistent with this diagnosis? (Select all that apply.)
- AUnilateral leg edema✓ 正解單側下肢水腫
- BPain in the calf upon palpation✓ 正解觸按小腿時感到疼痛
- CCoolness of the affected extremity患肢冰冷
- DRedness and warmth of the skin✓ 正解皮膚紅腫發熱
- EPositive Homans' sign✓ 正解Homans 徵象陽性
— Explanation · 中文詳解 —
深層靜脈栓塞的典型表現為患側肢體出現單側水腫、壓痛、發紅與溫熱感。雖然 Homans' sign 的敏感度在現代醫學中受爭議，但在 NCLEX 考試中仍被列為 DVT 的相關評估發現。患肢溫度應為溫熱，而非冷卻（冷卻通常提示動脈灌流不足）。
The typical presentation of deep vein thrombosis includes unilateral limb edema, tenderness, redness, and warmth of the affected extremity. Although the sensitivity of Homans' sign is debated in contemporary medicine, on the NCLEX it is still listed as an assessment finding associated with DVT. The affected limb should feel warm rather than cool (coolness usually suggests insufficient arterial perfusion).
✦ 台美臨床差異
美台對 Homans' sign 的臨床信賴度皆下降，但考試題目中仍維持其經典定義，臨床診斷多依賴血管超音波。