— 降低風險 · MEDIUM · SATA —
護理師照護一位疑似靜脈栓塞（VTE）的病人。預期會發現下列哪些徵象？（選所有適合的）
A nurse is caring for a client with a suspected venous thromboembolism (VTE). Which of the following findings should the nurse expect? (Select all that apply.)
- AUnilateral leg swelling✓ 正解單側腿部腫脹
- BRedness and warmth of the affected area✓ 正解患處發紅與發熱
- CPain or tenderness along the deep veins✓ 正解沿著深層靜脈的疼痛或壓痛
- DBilateral edema of both legs雙腿雙側水腫
- EPositive Homan's signHoman 徵象陽性
— Explanation · 中文詳解 —
VTE 典型的臨床表徵是單側下肢症狀，包括腫脹、發紅、發熱及壓痛。Bilateral edema（雙側腫脹）較常與心衰竭或腎衰竭相關。Homan's sign（背屈足部引發疼痛）雖曾為診斷參考，但臨床特異性與敏感度極低，目前不建議作為主要診斷依據。
Venous thromboembolism typically presents with unilateral leg swelling, redness, warmth, and tenderness along the deep veins due to local inflammation. Bilateral edema suggests systemic issues like heart failure, while Homan’s sign is no longer considered a reliable diagnostic indicator.
✦ 台美臨床差異
兩國臨床均已降低對 Homan's sign 的依賴，改用 Wells Criteria 作為診斷評估依據。