A nurse is setting goals for a patient who has Stage 4 Breast cancer, is in hospice care, and is at the end of life.
Which of the following are realistic goals?
The patient will increase attendance at community social activities.
The patient will receive medication to minimize episodes of breakthrough pain.
The patient will experience a weight gain of one to two pounds per week.
The patient will verbalize an understanding of the mode of disease transmission.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While hypertension is a risk factor for stroke, it is a modifiable risk factor. This means it can be controlled and managed through lifestyle changes and medication.
Choice B rationale
Family history is a non-modifiable risk factor for stroke. If a close family member, like a parent or sibling, has had a stroke, a person’s risk of stroke is slightly higher.
Choice C rationale
Smoking is a modifiable risk factor for stroke. Quitting smoking can significantly reduce the risk of stroke.
Choice D rationale
Obesity is a modifiable risk factor for stroke. Maintaining a healthy weight through diet and regular exercise can help reduce the risk of stroke.
Correct Answer is C
Explanation
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.
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