— 生理適應 · MEDIUM · SATA —
護理師正在評估一位疑似深層靜脈栓塞（DVT）的病人。下列哪些症狀是預期會出現的？（選所有適合的）
A nurse is assessing a client with suspected deep vein thrombosis (DVT). Which manifestations should the nurse expect to find? (Select all that apply.)
- ALocalized warmth in the calf area✓ 正解小腿局部發熱
- BUnilateral leg swelling✓ 正解單側腿部腫脹
- CPitting edema in both lower extremities雙下肢凹陷性水腫
- DTenderness along the course of the deep vein✓ 正解沿著靜脈走行的壓痛
- ESkin pallor and coolness of the limb皮膚蒼白且肢體冰冷
— Explanation · 中文詳解 —
DVT 典型表現為單側肢體受影響，因局部阻塞導致靜脈回流受阻，出現腫脹、發熱及壓痛（Homans' sign 概念但現較少使用）。雙側水腫通常指向全身性因素如心衰竭；皮膚蒼白與冰冷通常與動脈阻塞而非靜脈阻塞有關。
DVT typically presents as unilateral limb involvement, with local obstruction impairing venous return and causing swelling, warmth, and tenderness (the Homans' sign concept, though now used less commonly). Bilateral edema usually points to systemic factors such as heart failure; skin pallor and coolness are typically associated with arterial rather than venous occlusion.
✦ 台美臨床差異
美國非常強調 DVT 預防方案（如 Wells Criteria 使用），台灣臨床則較依賴醫師超音波診斷與評估。