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 — Assessment:
Data Collection & Validity
Stem
A 68-year-old postoperative client reports shortness of breath,
oxygen saturation 89% on room air, lung auscultation with
,bibasilar crackles, and decreased urine output over 6 hours.
Which nursing action best represents accurate assessment data
collection before formulating a nursing diagnosis?
A. Record the client's statement "I feel short of breath" and
proceed to plan interventions.
B. Reassess oxygen saturation and lung sounds, compare with
baseline, and document objective findings.
C. Initiate diuretic administration based on decreased urine
output.
D. Delegate oxygen therapy to nursing assistant and continue
planned monitoring.
Correct answer: B
Rationales
• Correct (B): The Nurse’s Pocket Guide emphasizes
systematic collection and verification of objective data and
comparison with baseline before diagnosing; reassessment
and documentation ensure accurate cues for diagnosis and
priority setting.
• Incorrect (A): Subjective report is important but
insufficient alone; objective verification is required before
planning interventions.
• Incorrect (C): Medication administration is a dependent
action requiring prescriber order and is premature without
confirmatory assessment and communication.
, • Incorrect (D): Delegation may be appropriate for tasks but
clinical reassessment and interpretation remain the nurse’s
responsibility.
Teaching point: Always verify subjective reports with objective,
baseline-comparative data before diagnosing.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
2
Reference
The Nursing Process and Planning Client Care — Diagnosis:
Problem Identification & Diagnostic Cues
Stem
A client with left-sided weakness after stroke demonstrates
inability to move left arm, drooping left mouth, and expressive
aphasia. Which nursing diagnosis is best supported by these
defining characteristics?
A. Risk for Injury
B. Impaired Physical Mobility
C. Ineffective Airway Clearance
D. Impaired Verbal Communication
Correct answer: B
Rationales
, • Correct (B): The Pocket Guide links objective motor deficits
(inability to move limb) and functional limitation to
Impaired Physical Mobility as the primary nursing
diagnosis.
• Incorrect (A): Risk for Injury may be present but is not the
best match to actual motor deficits observed; it is
secondary or concurrent.
• Incorrect (C): Airway clearance is not indicated by the
presented neurologic deficits.
• Incorrect (D): Impaired Verbal Communication fits
expressive aphasia but is not the best single diagnosis
when mobility is directly evidenced and functionally
limiting.
Teaching point: Match the most specific nursing diagnosis to
the dominant defining characteristics.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
3
Reference
The Nursing Process and Planning Client Care — Outcome
Identification: Writing Measurable Outcomes
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 — Assessment:
Data Collection & Validity
Stem
A 68-year-old postoperative client reports shortness of breath,
oxygen saturation 89% on room air, lung auscultation with
,bibasilar crackles, and decreased urine output over 6 hours.
Which nursing action best represents accurate assessment data
collection before formulating a nursing diagnosis?
A. Record the client's statement "I feel short of breath" and
proceed to plan interventions.
B. Reassess oxygen saturation and lung sounds, compare with
baseline, and document objective findings.
C. Initiate diuretic administration based on decreased urine
output.
D. Delegate oxygen therapy to nursing assistant and continue
planned monitoring.
Correct answer: B
Rationales
• Correct (B): The Nurse’s Pocket Guide emphasizes
systematic collection and verification of objective data and
comparison with baseline before diagnosing; reassessment
and documentation ensure accurate cues for diagnosis and
priority setting.
• Incorrect (A): Subjective report is important but
insufficient alone; objective verification is required before
planning interventions.
• Incorrect (C): Medication administration is a dependent
action requiring prescriber order and is premature without
confirmatory assessment and communication.
, • Incorrect (D): Delegation may be appropriate for tasks but
clinical reassessment and interpretation remain the nurse’s
responsibility.
Teaching point: Always verify subjective reports with objective,
baseline-comparative data before diagnosing.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
2
Reference
The Nursing Process and Planning Client Care — Diagnosis:
Problem Identification & Diagnostic Cues
Stem
A client with left-sided weakness after stroke demonstrates
inability to move left arm, drooping left mouth, and expressive
aphasia. Which nursing diagnosis is best supported by these
defining characteristics?
A. Risk for Injury
B. Impaired Physical Mobility
C. Ineffective Airway Clearance
D. Impaired Verbal Communication
Correct answer: B
Rationales
, • Correct (B): The Pocket Guide links objective motor deficits
(inability to move limb) and functional limitation to
Impaired Physical Mobility as the primary nursing
diagnosis.
• Incorrect (A): Risk for Injury may be present but is not the
best match to actual motor deficits observed; it is
secondary or concurrent.
• Incorrect (C): Airway clearance is not indicated by the
presented neurologic deficits.
• Incorrect (D): Impaired Verbal Communication fits
expressive aphasia but is not the best single diagnosis
when mobility is directly evidenced and functionally
limiting.
Teaching point: Match the most specific nursing diagnosis to
the dominant defining characteristics.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
3
Reference
The Nursing Process and Planning Client Care — Outcome
Identification: Writing Measurable Outcomes
