— 生理適應 · HARD · MCQ —
護理師評估一位疑似深層靜脈栓塞（DVT）的病人，下列哪項發現最令人擔憂？
A nurse is assessing a client with suspected deep vein thrombosis (DVT). Which finding is most concerning?
- AUnilateral calf swelling and redness單側小腿腫脹和發紅
- BPositive Homans' sign霍曼氏徵象陽性
- CSudden onset of shortness of breath and chest pain✓ 正解突然發作的呼吸困難和胸痛
- DWarmth at the site of the suspected clot疑似血栓部位的皮膚溫熱
— Explanation · 中文詳解 —
DVT 病人若出現突發性呼吸困難與胸痛，強烈暗示栓子已脫落並造成肺栓塞（PE），這是危及生命的緊急併發症。雖然單側腫脹、發紅與溫熱（A, D）是 DVT 本身的症狀，但 PE 屬於呼吸循環的立即威脅，優先級最高。
While unilateral swelling and warmth are signs of DVT, sudden onset of shortness of breath and chest pain is the most concerning finding as it indicates a potential pulmonary embolism. This is a life-threatening emergency requiring immediate intervention, unlike local inflammatory signs.
✦ 台美臨床差異
美國臨床已幾乎摒棄 Homans' sign，台灣部分資深人員仍會評估，但教學上已強調其不可靠性。