Nurse's Pocket Guide, 16th Edition
Diagnoses, Prioritized Interventions,
And Rationales
16th Edition
• Author(S)Marilynn E. Doenges; Mary
Frances Moorhouse; Alice C. Murr
TEST BANK
1
Reference
The Nursing Process — Steps & Purpose (Assessment →
Diagnosis → Planning → Implementation → Evaluation)
Stem
A 68-year-old client is admitted with new onset confusion, fever
38.9°C, and productive cough. The nurse lists problems after
,data collection. Which action best represents the assessment
step of the nursing process?
A. Formulating the nursing diagnosis “Risk for injury.”
B. Recording the client’s temperature, breath sounds, and
sputum color.
C. Teaching the client how to cough and deep-breathe.
D. Evaluating whether the client’s confusion resolved after
treatment.
Correct answer: B
Rationales
• Correct (B): Assessment is the systematic collection and
documentation of subjective and objective data (e.g.,
temperature, breath sounds, sputum). This is the
foundational step used to identify client problems in the
Nurse’s Pocket Guide.
• A: Formulating a nursing diagnosis is the diagnosis step,
which follows data collection.
• C: Teaching is an implementation/intervention activity, not
assessment.
• D: Evaluation occurs after interventions are implemented
to judge outcome attainment.
Teaching point: Assessment = systematic data collection
(subjective + objective).
,Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
2
Reference
Nursing Diagnosis — Actual vs. Risk Diagnoses; Defining
Characteristics
Stem
A postoperative client reports “sharp pain 8/10” at incision;
wound is red and client avoids movement. According to Chapter
1, which is the most appropriate nursing diagnosis statement?
A. Risk for infection related to surgical incision.
B. Acute pain related to tissue incision as evidenced by verbal
report 8/10 and guarding.
C. Ineffective breathing pattern related to pain.
D. Impaired physical mobility related to unknown cause.
Correct answer: B
Rationales
• Correct (B): An actual diagnosis uses defining
characteristics (subjective report 8/10, guarding) to
support the diagnosis; this follows the textbook guidance
to link defining characteristics with diagnosis.
• A: Risk diagnoses lack defining characteristics—this client
has actual signs/symptoms, so risk is lower priority.
, • C: Ineffective breathing pattern is not supported by the
provided assessment (no respiratory findings).
• D: “Unknown cause” is vague; the mobility limitation is
clearly related to pain and should be stated accordingly.
Teaching point: Actual diagnoses require defining
characteristics; risks do not.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
3
Reference
Priority Setting — ABCs, Safety, Acute vs. Chronic
Stem
While admitting four clients, the nurse must choose which
problem to address first. Which client should receive the nurse’s
immediate priority according to the prioritization guidance in
Chapter 1?
A. Client with blood glucose 210 mg/dL and thirst.
B. Client reporting new chest pain and shortness of breath.
C. Client requesting discharge teaching about wound care.
D. Client with chronic low back pain rating 5/10.
Correct answer: B
Rationales
Diagnoses, Prioritized Interventions,
And Rationales
16th Edition
• Author(S)Marilynn E. Doenges; Mary
Frances Moorhouse; Alice C. Murr
TEST BANK
1
Reference
The Nursing Process — Steps & Purpose (Assessment →
Diagnosis → Planning → Implementation → Evaluation)
Stem
A 68-year-old client is admitted with new onset confusion, fever
38.9°C, and productive cough. The nurse lists problems after
,data collection. Which action best represents the assessment
step of the nursing process?
A. Formulating the nursing diagnosis “Risk for injury.”
B. Recording the client’s temperature, breath sounds, and
sputum color.
C. Teaching the client how to cough and deep-breathe.
D. Evaluating whether the client’s confusion resolved after
treatment.
Correct answer: B
Rationales
• Correct (B): Assessment is the systematic collection and
documentation of subjective and objective data (e.g.,
temperature, breath sounds, sputum). This is the
foundational step used to identify client problems in the
Nurse’s Pocket Guide.
• A: Formulating a nursing diagnosis is the diagnosis step,
which follows data collection.
• C: Teaching is an implementation/intervention activity, not
assessment.
• D: Evaluation occurs after interventions are implemented
to judge outcome attainment.
Teaching point: Assessment = systematic data collection
(subjective + objective).
,Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
2
Reference
Nursing Diagnosis — Actual vs. Risk Diagnoses; Defining
Characteristics
Stem
A postoperative client reports “sharp pain 8/10” at incision;
wound is red and client avoids movement. According to Chapter
1, which is the most appropriate nursing diagnosis statement?
A. Risk for infection related to surgical incision.
B. Acute pain related to tissue incision as evidenced by verbal
report 8/10 and guarding.
C. Ineffective breathing pattern related to pain.
D. Impaired physical mobility related to unknown cause.
Correct answer: B
Rationales
• Correct (B): An actual diagnosis uses defining
characteristics (subjective report 8/10, guarding) to
support the diagnosis; this follows the textbook guidance
to link defining characteristics with diagnosis.
• A: Risk diagnoses lack defining characteristics—this client
has actual signs/symptoms, so risk is lower priority.
, • C: Ineffective breathing pattern is not supported by the
provided assessment (no respiratory findings).
• D: “Unknown cause” is vague; the mobility limitation is
clearly related to pain and should be stated accordingly.
Teaching point: Actual diagnoses require defining
characteristics; risks do not.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
3
Reference
Priority Setting — ABCs, Safety, Acute vs. Chronic
Stem
While admitting four clients, the nurse must choose which
problem to address first. Which client should receive the nurse’s
immediate priority according to the prioritization guidance in
Chapter 1?
A. Client with blood glucose 210 mg/dL and thirst.
B. Client reporting new chest pain and shortness of breath.
C. Client requesting discharge teaching about wound care.
D. Client with chronic low back pain rating 5/10.
Correct answer: B
Rationales
