A nurse is caring for a client who has deep vein thrombosis (DVT) of their right lower leg. Which manifestations should the nurse identify? Select all that apply

A. Erythema, or redness of the skin, occurs in DVT due to the inflammatory response triggered by the presence of a thrombus within the venous system. The localized obstruction of blood flow leads to venous congestion and the release of inflammatory mediators, which cause vasodilation of the surrounding superficial vessels. This is a classic objective sign that helps the nurse differentiate DVT from other non-inflammatory vascular conditions. B. Numbness is generally associated with neurological impairment or arterial insufficiency rather than venous thrombosis. While severe swelling from a DVT could theoretically compress peripheral nerves, it is not a hallmark or expected manifestation of a standard venous clot. The nurse should focus on signs of venous congestion and inflammation rather than sensory deficits when assessing for the presence of a lower extremity thrombus. C. Swelling of the affected extremity is a primary manifestation of DVT caused by the backup of venous blood behind the obstructive clot. This increase in hydrostatic pressure within the veins forces fluid into the interstitial spaces, resulting in localized edema. Measuring the circumference of the calf or thigh is a common nursing intervention to objectively quantify the extent of the swelling and monitor for progression. D. Warmth in the area of the thrombus is a result of the localized inflammatory process and increased blood flow to the surrounding tissues as the body reacts to the clot. The accumulation of metabolic byproducts and the activity of the immune system generate heat that can be palpated during a physical assessment. This finding, combined with redness and swelling, forms the characteristic clinical triad of a deep vein thrombosis. E. Bleeding is not a manifestation of DVT; in fact, DVT is a condition characterized by excessive or inappropriate clot formation. While the medications used to treat DVT, such as heparin or warfarin, can cause bleeding as a side effect, the disease process itself does not. The nurse must distinguish between the symptoms of the pathology and the potential adverse effects of the pharmacological interventions prescribed for the client.