A nurse is planning care for a patient who is immobile and is experiencing urinary retention.
The nurse should plan to monitor the patient for which of the following?

Choice A rationale
Increasing attendance at community social activities may not be a realistic goal for a patient in hospice care with Stage 4 breast cancer. The patient’s physical condition and energy levels may limit their ability to participate in such activities.
Choice B rationale
Receiving medication to minimize episodes of breakthrough pain is a realistic and important goal for a patient in hospice care. Effective pain management is a key aspect of end-of-life care.
Choice C rationale
Experiencing a weight gain of one to two pounds per week may not be a realistic goal for a patient in hospice care with Stage 4 breast cancer. Patients at this stage of illness often experience weight loss, not gain.
Choice D rationale
Verbalizing an understanding of the mode of disease transmission may not be a relevant goal for a patient in hospice care with Stage 4 breast cancer. The focus of care at this stage is typically on comfort and quality of life, rather than disease education.

Choice A rationale
Checking the patient’s visual acuity using a Snellen chart is used to assess cranial nerve II (Optic), not cranial nerve XI (Spinal Accessory)3.
Choice B rationale
Whispering in one of the patient’s ears while blocking the other is a method used to assess cranial nerve VIII (Vestibulocochlear), not cranial nerve XI4.
Choice C rationale
Observing the patient’s ability to turn their head from side to side is a correct method to assess cranial nerve XI. This nerve innervates the sternocleidomastoid and trapezius muscles, which are responsible for turning the head and shrugging the shoulders respectively.
Choice D rationale
Asking the patient to identify specific smells is used to assess cranial nerve I (Olfactory), not cranial nerve XI3.