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
MCQ 1
Reference
Nursing Process — Assessment vs. Diagnosis Differentiation
Question Stem
A nurse is collecting data on a postoperative client who reports
incisional pain rated 7/10, shallow respirations, and reluctance
to cough. Vital signs show tachycardia and mild hypertension.
,Before formulating nursing diagnoses, which nursing action is
most appropriate?
Options
A. Identify Acute Pain as the priority nursing diagnosis
B. Validate and cluster subjective and objective assessment data
C. Implement pain management interventions
D. Evaluate the client’s response to analgesics
Correct Answer
B
Rationales
Correct: The Nurse’s Pocket Guide emphasizes that accurate
nursing diagnoses depend on complete, validated assessment
data. Clustering subjective and objective cues is essential before
diagnostic labeling. Premature diagnosis risks inaccuracy and
unsafe planning.
Incorrect A: Diagnosis cannot occur before data validation and
clustering.
Incorrect C: Interventions follow diagnosis and planning, not
assessment.
Incorrect D: Evaluation occurs after interventions are
implemented.
Teaching Point
Assessment must be complete before diagnosis.
Citation
,Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse’s
Pocket Guide (16th ed.). Nursing process section.
MCQ 2
Reference
Nursing Diagnosis — Defining Characteristics vs. Related Factors
Question Stem
A client with pneumonia exhibits dyspnea, crackles, oxygen
saturation of 88%, and restlessness. Which assessment findings
best support the defining characteristics of a nursing diagnosis?
Options
A. Dyspnea and crackles
B. Smoking history and age
C. Physician’s diagnosis of pneumonia
D. Prescribed oxygen therapy
Correct Answer
A
Rationales
Correct: Defining characteristics are observable or reported
cues that validate a nursing diagnosis. Dyspnea and crackles are
direct clinical manifestations consistent with diagnostic criteria.
Incorrect B: These are risk or contributing factors, not defining
characteristics.
, Incorrect C: Medical diagnoses do not define nursing diagnoses.
Incorrect D: Treatments are not diagnostic cues.
Teaching Point
Defining characteristics validate nursing diagnoses.
Citation
Doenges et al. (2022). Nurse’s Pocket Guide (16th ed.).
Diagnostic components section.
MCQ 3
Reference
Priority Setting — Maslow’s Hierarchy
Question Stem
A nurse is caring for four clients. Which nursing diagnosis
requires the highest priority according to the Nurse’s Pocket
Guide framework?
Options
A. Disturbed Sleep Pattern
B. Impaired Gas Exchange
C. Chronic Low Self-Esteem
D. Deficient Knowledge
Correct Answer
B
Diagnoses, Prioritized Interventions,
And Rationales
16th Edition
• Author(S)Marilynn E. Doenges; Mary
Frances Moorhouse; Alice C. Murr
TEST BANK
MCQ 1
Reference
Nursing Process — Assessment vs. Diagnosis Differentiation
Question Stem
A nurse is collecting data on a postoperative client who reports
incisional pain rated 7/10, shallow respirations, and reluctance
to cough. Vital signs show tachycardia and mild hypertension.
,Before formulating nursing diagnoses, which nursing action is
most appropriate?
Options
A. Identify Acute Pain as the priority nursing diagnosis
B. Validate and cluster subjective and objective assessment data
C. Implement pain management interventions
D. Evaluate the client’s response to analgesics
Correct Answer
B
Rationales
Correct: The Nurse’s Pocket Guide emphasizes that accurate
nursing diagnoses depend on complete, validated assessment
data. Clustering subjective and objective cues is essential before
diagnostic labeling. Premature diagnosis risks inaccuracy and
unsafe planning.
Incorrect A: Diagnosis cannot occur before data validation and
clustering.
Incorrect C: Interventions follow diagnosis and planning, not
assessment.
Incorrect D: Evaluation occurs after interventions are
implemented.
Teaching Point
Assessment must be complete before diagnosis.
Citation
,Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse’s
Pocket Guide (16th ed.). Nursing process section.
MCQ 2
Reference
Nursing Diagnosis — Defining Characteristics vs. Related Factors
Question Stem
A client with pneumonia exhibits dyspnea, crackles, oxygen
saturation of 88%, and restlessness. Which assessment findings
best support the defining characteristics of a nursing diagnosis?
Options
A. Dyspnea and crackles
B. Smoking history and age
C. Physician’s diagnosis of pneumonia
D. Prescribed oxygen therapy
Correct Answer
A
Rationales
Correct: Defining characteristics are observable or reported
cues that validate a nursing diagnosis. Dyspnea and crackles are
direct clinical manifestations consistent with diagnostic criteria.
Incorrect B: These are risk or contributing factors, not defining
characteristics.
, Incorrect C: Medical diagnoses do not define nursing diagnoses.
Incorrect D: Treatments are not diagnostic cues.
Teaching Point
Defining characteristics validate nursing diagnoses.
Citation
Doenges et al. (2022). Nurse’s Pocket Guide (16th ed.).
Diagnostic components section.
MCQ 3
Reference
Priority Setting — Maslow’s Hierarchy
Question Stem
A nurse is caring for four clients. Which nursing diagnosis
requires the highest priority according to the Nurse’s Pocket
Guide framework?
Options
A. Disturbed Sleep Pattern
B. Impaired Gas Exchange
C. Chronic Low Self-Esteem
D. Deficient Knowledge
Correct Answer
B
