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
Nursing Process and Planning Client Care — Data Collection &
Cue Recognition
Stem
A 68-year-old post-op client reports "I feel short of breath" and
has an oxygen saturation of 88% on room air, respiratory rate
,28, and bilateral crackles heard on auscultation. When
organizing assessment data for diagnosis, which action best
reflects correct cue recognition and initial prioritization?
A. Cluster the subjective complaint with the low SpO₂ and
crackles and identify gas-exchange impairment as priority.
B. Record the subjective complaint separately and wait for
repeat vitals before clustering with objective data.
C. Assign a pain-related diagnosis because postoperative clients
commonly report discomfort that limits deep breathing.
D. Document only the objective findings and defer subjective
data to the primary provider.
Correct answer: A
Rationale
Correct (A): Chapter 1 emphasizes collecting both subjective
and objective cues and clustering them to identify patterns; the
combination of dyspnea, low SpO₂, tachypnea, and crackles
directs the nurse to prioritize a gas-exchange problem. This
supports immediate nursing diagnosis and timely interventions.
(Doenges et al., 16th ed.)
Incorrect (B): Waiting for repeat vitals delays clustering and
action; the nurse should integrate available cues now.
Incorrect (C): Although postoperative pain may affect
respiration, current objective respiratory findings and
hypoxemia make gas-exchange concerns higher priority.
Incorrect (D): Omitting the patient's subjective report violates
,comprehensive assessment principles and risks missing patient-
centered cues.
Teaching point: Cluster subjective and objective cues
immediately to identify priority physiologic problems.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
2
Reference
Nursing Process and Planning Client Care — Nursing Diagnosis
Selection (Actual vs. Risk)
Stem
A 45-year-old client with new spinal cord injury is incontinent
and has a stage I sacral pressure area. Skin is intact but
reddened and does not blanch. The client is immobile and has
poor nutritional intake. Which nursing diagnosis from Chapter 1
is most appropriate to record now?
A. Risk for Impaired Skin Integrity related to immobility and
poor nutrition.
B. Impaired Skin Integrity related to stage I pressure-related
tissue damage.
C. Risk for Infection related to skin redness.
D. Disturbed Body Image related to incontinence.
Correct answer: B
, Rationale
Correct (B): Chapter 1 directs distinguishing actual versus risk
diagnoses based on data. A nonblanching reddened area
indicates actual tissue damage (stage I), supporting Impaired
Skin Integrity as an actual problem requiring interventions now.
Incorrect (A): "Risk for" is inappropriate when objective
evidence of actual skin alteration exists.
Incorrect (C): Infection risk may be present but is not the most
immediate diagnosis for documented skin alteration.
Incorrect (D): Disturbed Body Image may be relevant later but is
not the priority nursing diagnosis for current skin breakdown.
Teaching point: Use objective evidence (e.g., nonblanching
erythema) to choose actual, not risk, diagnoses.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
3
Reference
Nursing Process and Planning Client Care — Writing Measurable
Outcomes
Stem
A client with heart failure has shortness of breath on minimal
exertion. The nurse writes an outcome: "Client will breathe
easier." Which rewritten outcome follows Chapter 1 guidance
for measurable, client-centered outcomes?
Diagnoses, Prioritized Interventions,
And Rationales
16th Edition
• Author(S)Marilynn E. Doenges; Mary
Frances Moorhouse; Alice C. Murr
TEST BANK
1
Reference
Nursing Process and Planning Client Care — Data Collection &
Cue Recognition
Stem
A 68-year-old post-op client reports "I feel short of breath" and
has an oxygen saturation of 88% on room air, respiratory rate
,28, and bilateral crackles heard on auscultation. When
organizing assessment data for diagnosis, which action best
reflects correct cue recognition and initial prioritization?
A. Cluster the subjective complaint with the low SpO₂ and
crackles and identify gas-exchange impairment as priority.
B. Record the subjective complaint separately and wait for
repeat vitals before clustering with objective data.
C. Assign a pain-related diagnosis because postoperative clients
commonly report discomfort that limits deep breathing.
D. Document only the objective findings and defer subjective
data to the primary provider.
Correct answer: A
Rationale
Correct (A): Chapter 1 emphasizes collecting both subjective
and objective cues and clustering them to identify patterns; the
combination of dyspnea, low SpO₂, tachypnea, and crackles
directs the nurse to prioritize a gas-exchange problem. This
supports immediate nursing diagnosis and timely interventions.
(Doenges et al., 16th ed.)
Incorrect (B): Waiting for repeat vitals delays clustering and
action; the nurse should integrate available cues now.
Incorrect (C): Although postoperative pain may affect
respiration, current objective respiratory findings and
hypoxemia make gas-exchange concerns higher priority.
Incorrect (D): Omitting the patient's subjective report violates
,comprehensive assessment principles and risks missing patient-
centered cues.
Teaching point: Cluster subjective and objective cues
immediately to identify priority physiologic problems.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
2
Reference
Nursing Process and Planning Client Care — Nursing Diagnosis
Selection (Actual vs. Risk)
Stem
A 45-year-old client with new spinal cord injury is incontinent
and has a stage I sacral pressure area. Skin is intact but
reddened and does not blanch. The client is immobile and has
poor nutritional intake. Which nursing diagnosis from Chapter 1
is most appropriate to record now?
A. Risk for Impaired Skin Integrity related to immobility and
poor nutrition.
B. Impaired Skin Integrity related to stage I pressure-related
tissue damage.
C. Risk for Infection related to skin redness.
D. Disturbed Body Image related to incontinence.
Correct answer: B
, Rationale
Correct (B): Chapter 1 directs distinguishing actual versus risk
diagnoses based on data. A nonblanching reddened area
indicates actual tissue damage (stage I), supporting Impaired
Skin Integrity as an actual problem requiring interventions now.
Incorrect (A): "Risk for" is inappropriate when objective
evidence of actual skin alteration exists.
Incorrect (C): Infection risk may be present but is not the most
immediate diagnosis for documented skin alteration.
Incorrect (D): Disturbed Body Image may be relevant later but is
not the priority nursing diagnosis for current skin breakdown.
Teaching point: Use objective evidence (e.g., nonblanching
erythema) to choose actual, not risk, diagnoses.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
3
Reference
Nursing Process and Planning Client Care — Writing Measurable
Outcomes
Stem
A client with heart failure has shortness of breath on minimal
exertion. The nurse writes an outcome: "Client will breathe
easier." Which rewritten outcome follows Chapter 1 guidance
for measurable, client-centered outcomes?
