— 降低風險 · MEDIUM · SATA —
護理師評估一位懷疑深層靜脈栓塞（DVT）的病人，哪些發現與 DVT 臨床表現一致？（選所有適合的）
A nurse is performing an assessment on a client with a suspected deep vein thrombosis (DVT). Which assessment findings are consistent with DVT? (Select all that apply.)
- AUnilateral leg edema✓ 正解單側下肢水腫
- BCalf pain or tenderness✓ 正解小腿疼痛或壓痛
- CCool, pale extremity四肢冰冷蒼白
- DLocalized warmth over the affected area✓ 正解患處局部發熱
- EPeripheral pulses are absent周邊脈搏消失
— Explanation · 中文詳解 —
深層靜脈栓塞（Deep Vein Thrombosis, DVT）的核心病理在於靜脈血流淤滯、血管壁損傷及高凝狀態（Virchow's Triad）。臨床表現通常為單側的急性炎症反應，因深部靜脈阻塞導致血液回流受阻，造成局部組織水腫、壓力上升及發炎，進而產生疼痛與發熱感。護理評估應重點關注單側肢體的對稱性變化。
Deep vein thrombosis typically presents with unilateral leg edema, calf pain or tenderness, and localized warmth due to venous obstruction and inflammation. These signs distinguish DVT from arterial issues, which would present with coolness, pallor, and absent pulses.