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 (Planning Client Care)
Stem: A 68-year-old client is admitted after a hip fracture. Vital
signs stable. Nurse notes the client reports pain 8/10 (resting),
decreased right lower extremity ROM, inability to bear weight,
and is anxious about postoperative mobility. Which nursing
diagnosis is the most appropriate to document as the priority
,problem?
A. Anxiety related to anticipated loss of mobility
B. Acute Pain related to tissue injury (hip fracture)
C. Risk for Impaired Skin Integrity related to immobility
D. Impaired Physical Mobility related to fracture
Correct answer: B
Rationale — Correct: Acute Pain is prioritized because
uncontrolled severe pain compromises respiratory effort,
mobility, and recovery; immediate pain control is necessary to
permit assessment and safe mobilization. This aligns with
Nurse’s Pocket Guide guidance to prioritize problems that are
physiologic threats and impede other care.
Rationale — Incorrect A: Anxiety is important but secondary;
physiologic pain must be relieved first to reduce anxiety and
allow participation in care.
Rationale — Incorrect C: Risk problems are preventive priorities
but lower than an actual acute physiologic problem causing
distress.
Rationale — Incorrect D: Impaired Physical Mobility is relevant
but often results from pain and must be addressed after acute
pain control.
Teaching point: Treat acute physiologic threats (pain) before
addressing secondary psychosocial or risk diagnoses.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing process and
planning client care section.
,2
Reference: Outcomes (Writing Measurable, Patient-Centered
Goals)
Stem: A client with congestive heart failure will be discharged in
3 days. Which short-term patient outcome written by the nurse
best follows textbook guidance for measurable, time-framed
outcomes?
A. Client will demonstrate understanding of fluid restrictions.
B. Client will state reasons for fluid restriction prior to
discharge.
C. Client will adhere to fluid restriction.
D. Client’s fluid balance will be maintained within 500 mL net
fluid gain by discharge.
Correct answer: D
Rationale — Correct: Option D is measurable (fluid balance
value) and time-bound (by discharge), matching the Nurse’s
Pocket Guide recommendation to use specific, observable
criteria for outcomes.
Rationale — Incorrect A: “Demonstrate understanding” is
vague without measurable criteria or method of demonstration.
Rationale — Incorrect B: “State reasons” is measurable but less
directly tied to physiologic outcome than fluid balance.
Rationale — Incorrect C: “Adhere” is non-measurable without
defined parameters.
, Teaching point: Write outcomes that are observable, specific,
and time-limited.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing process and
planning client care section.
3
Reference: Nursing Diagnosis — Risk Versus Actual Diagnoses
(Planning Care Priorities)
Stem: A postoperative client has stable vitals, surgical dressing
intact, and hemoglobin slightly decreased from baseline but
within acceptable range. The client expresses moderate fatigue
but no active bleeding. Which action best reflects correct
priority and use of the nursing process?
A. Add “Risk for Bleeding” to the plan and institute continuous
bleeding precautions.
B. Cluster interventions for “Fatigue” and schedule rest periods
only.
C. Monitor hemoglobin trends and surgical site for bleeding,
and document expected findings.
D. Immediately transfuse packed RBCs because hemoglobin is
decreased.
Correct answer: C
Rationale — Correct: Monitoring and documenting trends is
appropriate when findings are stable and expected; the Pocket
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 (Planning Client Care)
Stem: A 68-year-old client is admitted after a hip fracture. Vital
signs stable. Nurse notes the client reports pain 8/10 (resting),
decreased right lower extremity ROM, inability to bear weight,
and is anxious about postoperative mobility. Which nursing
diagnosis is the most appropriate to document as the priority
,problem?
A. Anxiety related to anticipated loss of mobility
B. Acute Pain related to tissue injury (hip fracture)
C. Risk for Impaired Skin Integrity related to immobility
D. Impaired Physical Mobility related to fracture
Correct answer: B
Rationale — Correct: Acute Pain is prioritized because
uncontrolled severe pain compromises respiratory effort,
mobility, and recovery; immediate pain control is necessary to
permit assessment and safe mobilization. This aligns with
Nurse’s Pocket Guide guidance to prioritize problems that are
physiologic threats and impede other care.
Rationale — Incorrect A: Anxiety is important but secondary;
physiologic pain must be relieved first to reduce anxiety and
allow participation in care.
Rationale — Incorrect C: Risk problems are preventive priorities
but lower than an actual acute physiologic problem causing
distress.
Rationale — Incorrect D: Impaired Physical Mobility is relevant
but often results from pain and must be addressed after acute
pain control.
Teaching point: Treat acute physiologic threats (pain) before
addressing secondary psychosocial or risk diagnoses.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing process and
planning client care section.
,2
Reference: Outcomes (Writing Measurable, Patient-Centered
Goals)
Stem: A client with congestive heart failure will be discharged in
3 days. Which short-term patient outcome written by the nurse
best follows textbook guidance for measurable, time-framed
outcomes?
A. Client will demonstrate understanding of fluid restrictions.
B. Client will state reasons for fluid restriction prior to
discharge.
C. Client will adhere to fluid restriction.
D. Client’s fluid balance will be maintained within 500 mL net
fluid gain by discharge.
Correct answer: D
Rationale — Correct: Option D is measurable (fluid balance
value) and time-bound (by discharge), matching the Nurse’s
Pocket Guide recommendation to use specific, observable
criteria for outcomes.
Rationale — Incorrect A: “Demonstrate understanding” is
vague without measurable criteria or method of demonstration.
Rationale — Incorrect B: “State reasons” is measurable but less
directly tied to physiologic outcome than fluid balance.
Rationale — Incorrect C: “Adhere” is non-measurable without
defined parameters.
, Teaching point: Write outcomes that are observable, specific,
and time-limited.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing process and
planning client care section.
3
Reference: Nursing Diagnosis — Risk Versus Actual Diagnoses
(Planning Care Priorities)
Stem: A postoperative client has stable vitals, surgical dressing
intact, and hemoglobin slightly decreased from baseline but
within acceptable range. The client expresses moderate fatigue
but no active bleeding. Which action best reflects correct
priority and use of the nursing process?
A. Add “Risk for Bleeding” to the plan and institute continuous
bleeding precautions.
B. Cluster interventions for “Fatigue” and schedule rest periods
only.
C. Monitor hemoglobin trends and surgical site for bleeding,
and document expected findings.
D. Immediately transfuse packed RBCs because hemoglobin is
decreased.
Correct answer: C
Rationale — Correct: Monitoring and documenting trends is
appropriate when findings are stable and expected; the Pocket
