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 C
Explanation
Choice A rationale
Minimal assistance implies that the patient needs some help but can do most of the task on their own. In this case, the patient is able to stand up from a seated position using a cane for support, which suggests that they do not need assistance.
Choice B rationale
Moderate assistance implies that the patient needs more help to perform the task. The patient in the scenario is able to perform the task independently with the help of a cane.
Choice C rationale
No assistance means that the patient can perform the task independently. This is the most fitting answer because the patient is able to stand up from a seated position using a cane for support.
Choice D rationale
Maximum assistance implies that the patient is unable to perform the task without substantial help. This does not apply to the patient in the scenario as they are able to stand up independently with the help of a cane.
Correct Answer is D
Explanation
Choice A rationale
Initiating life-saving measures such as a rapid response call would not be appropriate in this context. The patient is in a hospice setting, which focuses on providing comfort and quality of life for patients who are nearing the end of life, rather than aggressive life-saving interventions.
Choice B rationale
Calling the provider because these signs and symptoms are abnormal would not be the correct response. In a hospice setting, these symptoms are expected and are indicative of the natural dying process.
Choice C rationale
The statement that rapid respirations that are unusually deep and regular are curative for the patient is incorrect. Cheyne-Stokes respirations, characterized by a pattern of increasing and then decreasing depth of breath followed by a period of apnea, are often seen in patients nearing the end of life. They are not curative but are a sign of the body’s decreasing metabolic demands and changing physiology as death approaches.
Choice D rationale
The nurse understanding that these are impending signs of death and are normal is the correct response. The symptoms described, including loss of appetite, swelling of the limbs, increased sleep, Cheyne-Stokes respirations, and hallucinations, are all common in the final stages of life.
Recognizing these signs can help the nurse provide appropriate care and support to the patient and their family during this time.
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