— 基本照護與舒適 · MEDIUM · MCQ —
一位長期臥床病人，下列哪項臨床發現需立即回報醫師？
A nurse is assessing a client who has been on bed rest for several days. Which clinical finding should the nurse report to the provider immediately?
- ACalf pain and redness✓ 正解小腿疼痛和紅腫
- BSlightly elevated temperature of 99.2 F體溫略高為99.2°F
- CComplaints of back stiffness抱怨背部僵硬
- DDecreased bowel sounds腸鳴音減弱
— Explanation · 中文詳解 —
長期臥床病人因血液循環減緩、靜脈瘀滯（Venous Stasis）以及血管內皮損傷，極易形成深層靜脈血栓（DVT）。臨床上若發現單側小腿疼痛、紅腫、發熱或周長增加，應高度懷疑 DVT 的發生。DVT 最危險的併發症是血栓脫落導致肺栓塞（PE），這屬於致命性的呼吸循環問題。基於優先順序（Priority），護理師須立即回報醫師進行診斷與抗凝血治療。
Calf pain and redness are classic signs of deep vein thrombosis (DVT), a serious complication of prolonged bed rest caused by venous stasis. Immediate reporting is required because a dislodged clot can lead to a life-threatening pulmonary embolism, making this finding the highest priority.