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 and Planning Client Care — Types of
Nursing Diagnoses & Diagnostic Statement Construction
Stem
A charge nurse reviews a new student's client note: “Risk for
falls R/T unsteady gait; evidenced by a recent fall earlier today.”
The student asks whether this wording is correct. Which
,response best explains the problem with the diagnostic
statement?
A. The diagnosis is correct; risk diagnoses may list a recent fall
as evidence.
B. The phrase “evidenced by” should not be used with a risk
diagnosis because risk NDs have no defining characteristics.
C. Replace “Risk for falls” with “Falls” to make it a problem-
focused diagnosis.
D. Keep wording but add a health-promotion outcome to
balance the statement.
Correct answer: B
Rationales
Correct (B): Chapter 1 explains risk nursing diagnoses describe
potential problems that have no current defining
characteristics; they are identified by risk factors, not
“evidenced by” cues. Using “evidenced by” incorrectly converts
a risk ND into a problem-focused ND and misrepresents the
client’s status.
Incorrect (A): Risk diagnoses should not list an actual event as
evidence—an actual fall is a defining event that would indicate
a problem-focused diagnosis, not a risk.
Incorrect (C): Changing the label to “Falls” is not standardized
NANDA-I wording; the pocket guide emphasizes using approved
NDs and correct diagnostic form.
Incorrect (D): Adding a health-promotion outcome does not
correct the misuse of “evidenced by” in a risk diagnosis.
,Teaching point: Risk NDs use risk factors; do not list defining
characteristics as “evidenced by.”
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 and Planning Client Care — Assessment
Database & Subjective vs. Objective Data
Stem
During admission assessment the client reports “I feel short of
breath when I walk.” Vital signs show RR 24, SpO₂ 92% on room
air, and bilateral crackles on auscultation. A student asks which
data should be used to confirm a nursing diagnosis. Which
combination best fits Chapter 1 guidance?
A. Use only subjective data for client-reported symptoms.
B. Use the subjective complaint plus objective signs that
support a diagnosis.
C. Rely on objective data only because subjective reports are
unreliable.
D. Defer diagnosis until physician tests are back because nurses
must have medical confirmation.
Correct answer: B
, Rationales
Correct (B): Chapter 1 emphasizes the assessment database
includes both subjective and objective data; diagnostic
confirmation requires clustering client-reported cues with
supporting objective findings to validate a nursing diagnosis.
Incorrect (A): Subjective data alone are important but
insufficient—defining characteristics should include objective
corroboration when possible.
Incorrect (C): Objective data are essential but ignoring the
client’s complaint violates holistic assessment principles.
Incorrect (D): Nurses use assessment data to identify nursing
diagnoses; medical tests may inform collaborative care but are
not always required to make appropriate nursing diagnoses.
Teaching point: Form diagnoses by clustering subjective
complaints with objective signs.
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 and Planning Client Care — Categories of
Nursing Diagnoses
Stem
A nurse is teaching peers about categories of nursing diagnoses
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 and Planning Client Care — Types of
Nursing Diagnoses & Diagnostic Statement Construction
Stem
A charge nurse reviews a new student's client note: “Risk for
falls R/T unsteady gait; evidenced by a recent fall earlier today.”
The student asks whether this wording is correct. Which
,response best explains the problem with the diagnostic
statement?
A. The diagnosis is correct; risk diagnoses may list a recent fall
as evidence.
B. The phrase “evidenced by” should not be used with a risk
diagnosis because risk NDs have no defining characteristics.
C. Replace “Risk for falls” with “Falls” to make it a problem-
focused diagnosis.
D. Keep wording but add a health-promotion outcome to
balance the statement.
Correct answer: B
Rationales
Correct (B): Chapter 1 explains risk nursing diagnoses describe
potential problems that have no current defining
characteristics; they are identified by risk factors, not
“evidenced by” cues. Using “evidenced by” incorrectly converts
a risk ND into a problem-focused ND and misrepresents the
client’s status.
Incorrect (A): Risk diagnoses should not list an actual event as
evidence—an actual fall is a defining event that would indicate
a problem-focused diagnosis, not a risk.
Incorrect (C): Changing the label to “Falls” is not standardized
NANDA-I wording; the pocket guide emphasizes using approved
NDs and correct diagnostic form.
Incorrect (D): Adding a health-promotion outcome does not
correct the misuse of “evidenced by” in a risk diagnosis.
,Teaching point: Risk NDs use risk factors; do not list defining
characteristics as “evidenced by.”
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 and Planning Client Care — Assessment
Database & Subjective vs. Objective Data
Stem
During admission assessment the client reports “I feel short of
breath when I walk.” Vital signs show RR 24, SpO₂ 92% on room
air, and bilateral crackles on auscultation. A student asks which
data should be used to confirm a nursing diagnosis. Which
combination best fits Chapter 1 guidance?
A. Use only subjective data for client-reported symptoms.
B. Use the subjective complaint plus objective signs that
support a diagnosis.
C. Rely on objective data only because subjective reports are
unreliable.
D. Defer diagnosis until physician tests are back because nurses
must have medical confirmation.
Correct answer: B
, Rationales
Correct (B): Chapter 1 emphasizes the assessment database
includes both subjective and objective data; diagnostic
confirmation requires clustering client-reported cues with
supporting objective findings to validate a nursing diagnosis.
Incorrect (A): Subjective data alone are important but
insufficient—defining characteristics should include objective
corroboration when possible.
Incorrect (C): Objective data are essential but ignoring the
client’s complaint violates holistic assessment principles.
Incorrect (D): Nurses use assessment data to identify nursing
diagnoses; medical tests may inform collaborative care but are
not always required to make appropriate nursing diagnoses.
Teaching point: Form diagnoses by clustering subjective
complaints with objective signs.
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 and Planning Client Care — Categories of
Nursing Diagnoses
Stem
A nurse is teaching peers about categories of nursing diagnoses
