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
Nursing Process and Care Planning MCQs
1.
• Reference: The Nursing Process - Assessment Phase
• Stem: A nurse admits a client with chronic obstructive
pulmonary disease (COPD). The client states, "I haven't
been able to catch my breath for two days, and I'm so tired
I can't even make my bed." The nurse notes the client is
using accessory muscles to breathe, has a respiratory rate
, of 28, and SpO2 is 88% on room air. Which piece of data
collected by the nurse is a subjective finding?
• Options:
A. Respiratory rate of 28 breaths per minute
B. Use of accessory muscles to breathe
C. Client's statement, "I'm so tired I can't even make my
bed"
D. Oxygen saturation of 88% on room air
• Correct Answer: C
• Rationales:
o Correct: Subjective data are the client's personal
perceptions, feelings, and statements, which cannot
be independently measured by the nurse. The client's
description of their fatigue is a classic example.
o Incorrect A: Respiratory rate is an objective,
measurable finding obtained through observation and
measurement.
o Incorrect B: Observation of muscle use is an objective
finding gathered through physical assessment.
o Incorrect D: Oxygen saturation is a measurable,
objective datum obtained through diagnostic
monitoring.
, • Teaching Point: Subjective data = what the client says;
Objective data = what the nurse observes, hears, or
measures.
• Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse's Pocket Guide (16th ed.). Chapter 1: The
Nursing Process and Planning Client Care.
2.
• Reference: The Nursing Process - Diagnosis Phase
• Stem: Based on the COPD client's data from the previous
question, the nurse clusters the following findings: patient
statement of shortness of breath, use of accessory
muscles, increased respiratory rate, and low oxygen
saturation. This cluster of findings best supports which
step of the nursing process?
• Options:
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
• Correct Answer: B
• Rationales:
o Correct: Clustering related assessment data to
identify a pattern is a critical activity in the Diagnosis
, phase, leading to the formulation of a nursing
diagnosis.
o Incorrect A: Assessment involves data collection, not
interpretation or clustering to identify patterns.
o Incorrect C: Planning involves setting goals and
selecting interventions, which occurs after a diagnosis
is identified.
o Incorrect D: Implementation is the action phase of
carrying out planned interventions.
• Teaching Point: Data clustering transforms collected facts
(assessment) into a clinical judgment (diagnosis).
• Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse's Pocket Guide (16th ed.). Chapter 1: The
Nursing Process and Planning Client Care.
3.
• Reference: The Nursing Process - Diagnosis Phase
• Stem: The nurse is reviewing the defining characteristics
for the nursing diagnosis "Activity Intolerance." Which of
the following findings, if documented in the client's chart,
would the nurse recognize as an objective defining
characteristic for this diagnosis?
• Options:
A. The client reports, "I feel weak when I try to walk."
B. The client states a verbal report of fatigue.
Diagnoses, Prioritized Interventions,
And Rationales
16th Edition
• Author(S)Marilynn E. Doenges; Mary
Frances Moorhouse; Alice C. Murr
TEST BANK
Nursing Process and Care Planning MCQs
1.
• Reference: The Nursing Process - Assessment Phase
• Stem: A nurse admits a client with chronic obstructive
pulmonary disease (COPD). The client states, "I haven't
been able to catch my breath for two days, and I'm so tired
I can't even make my bed." The nurse notes the client is
using accessory muscles to breathe, has a respiratory rate
, of 28, and SpO2 is 88% on room air. Which piece of data
collected by the nurse is a subjective finding?
• Options:
A. Respiratory rate of 28 breaths per minute
B. Use of accessory muscles to breathe
C. Client's statement, "I'm so tired I can't even make my
bed"
D. Oxygen saturation of 88% on room air
• Correct Answer: C
• Rationales:
o Correct: Subjective data are the client's personal
perceptions, feelings, and statements, which cannot
be independently measured by the nurse. The client's
description of their fatigue is a classic example.
o Incorrect A: Respiratory rate is an objective,
measurable finding obtained through observation and
measurement.
o Incorrect B: Observation of muscle use is an objective
finding gathered through physical assessment.
o Incorrect D: Oxygen saturation is a measurable,
objective datum obtained through diagnostic
monitoring.
, • Teaching Point: Subjective data = what the client says;
Objective data = what the nurse observes, hears, or
measures.
• Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse's Pocket Guide (16th ed.). Chapter 1: The
Nursing Process and Planning Client Care.
2.
• Reference: The Nursing Process - Diagnosis Phase
• Stem: Based on the COPD client's data from the previous
question, the nurse clusters the following findings: patient
statement of shortness of breath, use of accessory
muscles, increased respiratory rate, and low oxygen
saturation. This cluster of findings best supports which
step of the nursing process?
• Options:
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
• Correct Answer: B
• Rationales:
o Correct: Clustering related assessment data to
identify a pattern is a critical activity in the Diagnosis
, phase, leading to the formulation of a nursing
diagnosis.
o Incorrect A: Assessment involves data collection, not
interpretation or clustering to identify patterns.
o Incorrect C: Planning involves setting goals and
selecting interventions, which occurs after a diagnosis
is identified.
o Incorrect D: Implementation is the action phase of
carrying out planned interventions.
• Teaching Point: Data clustering transforms collected facts
(assessment) into a clinical judgment (diagnosis).
• Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse's Pocket Guide (16th ed.). Chapter 1: The
Nursing Process and Planning Client Care.
3.
• Reference: The Nursing Process - Diagnosis Phase
• Stem: The nurse is reviewing the defining characteristics
for the nursing diagnosis "Activity Intolerance." Which of
the following findings, if documented in the client's chart,
would the nurse recognize as an objective defining
characteristic for this diagnosis?
• Options:
A. The client reports, "I feel weak when I try to walk."
B. The client states a verbal report of fatigue.
