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 — Assessment & Diagnostic Reasoning
(Chapter 1)
Stem
A 68-year-old hospitalized man has newly increased confusion,
pulse 110/min, temperature 38.6°C (101.5°F), and family
reports he is "not acting like himself." The nurse's focused
,assessment documents decreased appetite and disorientation
to time. Which nursing action most appropriately reflects the
assessment step of the nursing process?
A. Formulate the nursing diagnosis "Acute Confusion related to
infection."
B. Collect additional data about recent medications, baseline
cognition, and onset/timeline.
C. Begin implementation of safety interventions (bed alarm,
sitter).
D. Write outcome: "Client will be oriented ×3 within 24 hours."
Correct answer: B
Rationales
Correct (B): Chapter 1 defines assessment as systematically
gathering and organizing data; collecting medication history,
baseline cognition, and onset/timeline is the next step to clarify
causes of acute change before labeling a diagnosis.
A: Premature—diagnosis should follow adequate data
collection and analysis.
C: Safety interventions may be needed but are part of
implementation; they do not replace completing assessment.
D: Writing outcomes is planning and depends on accurate
assessment and diagnosis.
Teaching point: Assessment = collect/organize data before
diagnosing or planning.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
,2
Reference
Nursing Process — Diagnosis: Problem-focused vs. Risk (Chapter
1)
Stem
A 45-year-old woman post-op appendectomy ambulates slowly
and reports calf pain in the right lower leg; calf is warm and
slightly swollen. Which diagnostic formulation is most
consistent with the nursing process guidance in Chapter 1?
A. Risk for Deep Vein Thrombosis related to immobility.
B. Acute Pain related to surgical incision.
C. Risk for Injury related to possible bleeding.
D. Impaired Tissue Perfusion: Peripheral related to suspected
venous thrombosis.
Correct answer: D
Rationales
Correct (D): Chapter 1 emphasizes using collected subjective
and objective cues to support a problem-focused diagnostic
statement; signs (calf pain, warmth, swelling) indicate an actual
problem (impaired tissue perfusion/peripheral circulation).
A: “Risk for” is for potential problems without current defining
characteristics; here objective signs are present.
B: Incision pain is plausible but does not address the specific
, calf findings.
C: No evidence of bleeding; this misapplies risk focus.
Teaching point: Use defining characteristics to choose problem-
focused rather than risk diagnoses.
Citation: Doenges et al. (2022), Chapter 1.
3
Reference
Nursing Process — Planning: Setting Priorities (Chapter 1)
Stem
During morning report, a nurse accepts assignment for four
clients. One client has difficulty breathing (respiratory rate
30/min, oxygen saturation 88% on room air), another reports
moderate pain after surgery, a third needs discharge teaching,
and the fourth requires routine medication. Based on the
nursing priorities described in Chapter 1, which client should be
assessed first?
A. The client with moderate postoperative pain.
B. The client needing discharge teaching.
C. The client with respiratory distress and low SpO₂.
D. The client requiring routine medication.
Correct answer: C
Rationales
Correct (C): Chapter 1 states prioritization follows
Diagnoses, Prioritized Interventions,
And Rationales
16th Edition
• Author(S)Marilynn E. Doenges; Mary
Frances Moorhouse; Alice C. Murr
TEST BANK
1
Reference
Nursing Process — Assessment & Diagnostic Reasoning
(Chapter 1)
Stem
A 68-year-old hospitalized man has newly increased confusion,
pulse 110/min, temperature 38.6°C (101.5°F), and family
reports he is "not acting like himself." The nurse's focused
,assessment documents decreased appetite and disorientation
to time. Which nursing action most appropriately reflects the
assessment step of the nursing process?
A. Formulate the nursing diagnosis "Acute Confusion related to
infection."
B. Collect additional data about recent medications, baseline
cognition, and onset/timeline.
C. Begin implementation of safety interventions (bed alarm,
sitter).
D. Write outcome: "Client will be oriented ×3 within 24 hours."
Correct answer: B
Rationales
Correct (B): Chapter 1 defines assessment as systematically
gathering and organizing data; collecting medication history,
baseline cognition, and onset/timeline is the next step to clarify
causes of acute change before labeling a diagnosis.
A: Premature—diagnosis should follow adequate data
collection and analysis.
C: Safety interventions may be needed but are part of
implementation; they do not replace completing assessment.
D: Writing outcomes is planning and depends on accurate
assessment and diagnosis.
Teaching point: Assessment = collect/organize data before
diagnosing or planning.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
,2
Reference
Nursing Process — Diagnosis: Problem-focused vs. Risk (Chapter
1)
Stem
A 45-year-old woman post-op appendectomy ambulates slowly
and reports calf pain in the right lower leg; calf is warm and
slightly swollen. Which diagnostic formulation is most
consistent with the nursing process guidance in Chapter 1?
A. Risk for Deep Vein Thrombosis related to immobility.
B. Acute Pain related to surgical incision.
C. Risk for Injury related to possible bleeding.
D. Impaired Tissue Perfusion: Peripheral related to suspected
venous thrombosis.
Correct answer: D
Rationales
Correct (D): Chapter 1 emphasizes using collected subjective
and objective cues to support a problem-focused diagnostic
statement; signs (calf pain, warmth, swelling) indicate an actual
problem (impaired tissue perfusion/peripheral circulation).
A: “Risk for” is for potential problems without current defining
characteristics; here objective signs are present.
B: Incision pain is plausible but does not address the specific
, calf findings.
C: No evidence of bleeding; this misapplies risk focus.
Teaching point: Use defining characteristics to choose problem-
focused rather than risk diagnoses.
Citation: Doenges et al. (2022), Chapter 1.
3
Reference
Nursing Process — Planning: Setting Priorities (Chapter 1)
Stem
During morning report, a nurse accepts assignment for four
clients. One client has difficulty breathing (respiratory rate
30/min, oxygen saturation 88% on room air), another reports
moderate pain after surgery, a third needs discharge teaching,
and the fourth requires routine medication. Based on the
nursing priorities described in Chapter 1, which client should be
assessed first?
A. The client with moderate postoperative pain.
B. The client needing discharge teaching.
C. The client with respiratory distress and low SpO₂.
D. The client requiring routine medication.
Correct answer: C
Rationales
Correct (C): Chapter 1 states prioritization follows
