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 — The Nursing Process and
Planning Client Care.
Stem: A nurse completes a focused history and physical and
documents subjective and objective data in the database. The
next step the nurse performs to identify client problems is to:
A. Implement prescribed nursing actions.
B. Formulate nursing diagnoses by analyzing collected data.
,C. Evaluate client responses to prior interventions.
D. Discharge the client with teaching.
Correct answer: B
Rationale — Correct (B): Chapter 1 states that analysis of
collected subjective and objective data leads to identification
(diagnosis) of problems or needs expressed as nursing
diagnoses. Diagnosis organizes assessment data into problem
statements that direct care.
Rationale — Incorrect:
A. Implementation follows planning; implementing before
diagnosing is premature.
C. Evaluation occurs after interventions are in place; no
interventions yet were chosen.
D. Discharge and teaching are part of later
planning/intervention and require diagnosis first.
Teaching point: Assessment → data analysis → nursing
diagnoses guide planning.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
2
Reference: Types of Nursing Diagnoses — Chapter 1.
Stem: During admission the nurse recognizes a client has no
current signs but is at high risk for infection due to recent
surgery. Which category of nursing diagnosis best fits this
,scenario?
A. Problem-focused nursing diagnosis.
B. Risk nursing diagnosis.
C. Health promotion nursing diagnosis.
D. Syndrome nursing diagnosis.
Correct answer: B
Rationale — Correct (B): Chapter 1 describes risk NDs as
diagnoses that could develop because of specific client
vulnerabilities (e.g., surgery). They identify potential problems
before defining characteristics appear.
Rationale — Incorrect:
A. Problem-focused requires current defining characteristics
(signs/symptoms).
C. Health-promotion diagnoses reflect readiness to improve,
not vulnerability to harm.
D. Syndrome NDs describe a cluster of associated diagnoses,
not a single vulnerability.
Teaching point: Risk NDs identify potential problems before
signs develop.
Citation: Doenges et al., (2022), Chapter 1.
3
Reference: Diagnostic Divisions & Assessment Tool — Chapter 1
/ Appendix 1 summary.
Stem: A nurse uses a diagnostic-division-based assessment tool
, while admitting an older adult. What is the principal benefit of
this structured tool?
A. It replaces clinical judgment with checkboxes.
B. It helps the nurse readily identify appropriate nursing
diagnoses from collected data.
C. It mandates specific medical orders for each finding.
D. It limits documentation to only abnormal findings.
Correct answer: B
Rationale — Correct (B): The chapter explains that Diagnostic
Divisions support assessment tools designed to assist nurses in
identifying appropriate NDs as data are collected. They guide
clinical reasoning without replacing it.
Rationale — Incorrect:
A. Tools augment—not replace—clinical judgment.
C. Tools do not mandate medical orders; some interventions
remain collaborative.
D. Documentation should include relevant normal and
abnormal findings per documentation focus.
Teaching point: Diagnostic-division tools structure assessment
to prompt accurate diagnoses.
Citation: Doenges et al., (2022), Chapter 1.
4
Reference: Components of a Diagnostic Statement — Chapter
1.
Diagnoses, Prioritized Interventions,
And Rationales
16th Edition
• Author(S)Marilynn E. Doenges; Mary
Frances Moorhouse; Alice C. Murr
TEST BANK
1
Reference: Nursing Process — The Nursing Process and
Planning Client Care.
Stem: A nurse completes a focused history and physical and
documents subjective and objective data in the database. The
next step the nurse performs to identify client problems is to:
A. Implement prescribed nursing actions.
B. Formulate nursing diagnoses by analyzing collected data.
,C. Evaluate client responses to prior interventions.
D. Discharge the client with teaching.
Correct answer: B
Rationale — Correct (B): Chapter 1 states that analysis of
collected subjective and objective data leads to identification
(diagnosis) of problems or needs expressed as nursing
diagnoses. Diagnosis organizes assessment data into problem
statements that direct care.
Rationale — Incorrect:
A. Implementation follows planning; implementing before
diagnosing is premature.
C. Evaluation occurs after interventions are in place; no
interventions yet were chosen.
D. Discharge and teaching are part of later
planning/intervention and require diagnosis first.
Teaching point: Assessment → data analysis → nursing
diagnoses guide planning.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
2
Reference: Types of Nursing Diagnoses — Chapter 1.
Stem: During admission the nurse recognizes a client has no
current signs but is at high risk for infection due to recent
surgery. Which category of nursing diagnosis best fits this
,scenario?
A. Problem-focused nursing diagnosis.
B. Risk nursing diagnosis.
C. Health promotion nursing diagnosis.
D. Syndrome nursing diagnosis.
Correct answer: B
Rationale — Correct (B): Chapter 1 describes risk NDs as
diagnoses that could develop because of specific client
vulnerabilities (e.g., surgery). They identify potential problems
before defining characteristics appear.
Rationale — Incorrect:
A. Problem-focused requires current defining characteristics
(signs/symptoms).
C. Health-promotion diagnoses reflect readiness to improve,
not vulnerability to harm.
D. Syndrome NDs describe a cluster of associated diagnoses,
not a single vulnerability.
Teaching point: Risk NDs identify potential problems before
signs develop.
Citation: Doenges et al., (2022), Chapter 1.
3
Reference: Diagnostic Divisions & Assessment Tool — Chapter 1
/ Appendix 1 summary.
Stem: A nurse uses a diagnostic-division-based assessment tool
, while admitting an older adult. What is the principal benefit of
this structured tool?
A. It replaces clinical judgment with checkboxes.
B. It helps the nurse readily identify appropriate nursing
diagnoses from collected data.
C. It mandates specific medical orders for each finding.
D. It limits documentation to only abnormal findings.
Correct answer: B
Rationale — Correct (B): The chapter explains that Diagnostic
Divisions support assessment tools designed to assist nurses in
identifying appropriate NDs as data are collected. They guide
clinical reasoning without replacing it.
Rationale — Incorrect:
A. Tools augment—not replace—clinical judgment.
C. Tools do not mandate medical orders; some interventions
remain collaborative.
D. Documentation should include relevant normal and
abnormal findings per documentation focus.
Teaching point: Diagnostic-division tools structure assessment
to prompt accurate diagnoses.
Citation: Doenges et al., (2022), Chapter 1.
4
Reference: Components of a Diagnostic Statement — Chapter
1.
