The physician has ordered SoluMedrol 75 mg IM. How many milliliters will the nurse administer? (Use LABEL #4 - SoluMedrol: ROUND TO TENTHS PLACE: LABEL CORRECTLY TO RECEIVE CREDIT)

Choice A rationale

A positive Romberg sign is indicated when a patient, asked to stand with feet together and arms at their side with eyes closed, sways significantly or loses balance. This suggests a deficit in proprioception, which is the sense of one's body position in space, as visual input cannot compensate for the impaired proprioceptive feedback to maintain equilibrium.

Choice B rationale

Homans' sign is a clinical indicator for deep vein thrombosis (DVT), assessed by dorsiflexing the foot and observing for calf pain. A negative Homans' sign means no pain is present, and it is unrelated to balance or coordination assessment.

Choice C rationale

Lack of coordination is a general term that could encompass various motor deficits, but "ataxia" is a more specific neurological term for impaired coordination. While swaying and moving feet apart demonstrate a lack of coordination, documenting it as a positive Romberg sign provides a more precise and diagnostically relevant finding in this specific context.

Choice D rationale

Ataxia refers to impaired coordination of voluntary movements, often appearing as clumsiness, inaccuracy, or instability. While the patient's actions exhibit ataxia, the specific maneuver performed (standing with eyes closed) and the resulting sway are characteristic of a positive Romberg sign, which points to a proprioceptive or vestibular deficit.

Choice A rationale

Frostbite causes localized tissue damage due to ice crystal formation and cellular dehydration, leading to impaired circulation. While frostbite can affect capillary refill, a 5-second refill time in the absence of cold exposure or other correlating symptoms makes frostbite a less likely primary consideration and requires broader assessment.

Choice B rationale

Venous insufficiency involves impaired blood return to the heart, leading to venous stasis and edema. Capillary refill primarily assesses arterial perfusion and microcirculatory integrity, not venous outflow. Therefore, venous insufficiency would not typically manifest as a prolonged capillary refill time as a primary symptom.

Choice C rationale

Normal capillary refill time in adults is typically less than 2 seconds. A 5-second capillary refill time indicates impaired peripheral perfusion, suggesting inadequate blood flow to the capillaries. This delay warrants further investigation to identify underlying causes such as dehydration, hypovolemia, or peripheral vascular compromise.

Choice D rationale

Normal capillary refill time is typically less than 2 seconds. A 5-second refill time is significantly prolonged and indicates compromised peripheral circulation. Considering this normal would lead to a missed opportunity to identify and address a potentially serious underlying physiological issue affecting tissue perfusion.