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: Knowledge Deficit — Planning Client Care (Nursing
Process — Outcome Identification & Planning)
Stem: A 55-year-old client newly diagnosed with type 2
diabetes says, “I don’t know how to manage my medicines or
what to eat.” The nurse is planning care. Which nursing
outcome is most appropriate for the initial plan of care?
A. Client will demonstrate correct insulin injection technique by
,discharge.
B. Client will state the pathophysiology of diabetes in own
words within 48 hours.
C. Client will verbalize fear and grief related to diagnosis within
24 hours.
D. Client’s blood glucose will remain within normal range
without medication.
Correct answer: A
Rationales — Correct: Option A is a specific, measurable,
attainable short-term outcome focused on self-management
skills (knowledge → skill) consistent with planning care for a
Knowledge Deficit. Skill demonstration is priority for safety.
Incorrect: B is overly cognitive and not directly safety-focused;
it’s less measurable for discharge teaching. C is an affective goal
(valid) but not highest priority for immediate self-care safety. D
is unrealistic and may be unsafe to promise; it conflates medical
management with nursing teaching.
Teaching Point: Prioritize measurable skill-based outcomes for
Knowledge Deficit affecting self-care.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing diagnosis
section.
2
Reference: Risk for Falls — Planning Client Care (Nursing
Process — Prioritization & Safety Outcomes)
,Stem: An 82-year-old post-op client is on bed rest, requesting
help to the bathroom. The nurse plans outcomes. Which
outcome is most appropriate and measurable?
A. Client will not fall during hospitalization.
B. Client will use call light before ambulating for the next 48
hours.
C. Client will ambulate independently to the bathroom by
tomorrow.
D. Client will maintain muscle strength.
Correct answer: B
Rationales — Correct: Option B is specific, measurable, and
directly targets a safety behavior (call light use) to reduce fall
risk — an immediate nursing-planning focus.
Incorrect: A is a “never” goal and not specific or measurable by
nursing interventions. C may be unsafe and unrealistic given
recent surgery and bed rest. D is vague and not measurable in
the short term.
Teaching Point: Use specific, observable behaviors (call light
use) for fall-prevention outcomes.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing diagnosis
section.
3
Reference: Acute Pain — Planning Client Care (Nursing Process
— Interventions: Independent vs. Collaborative)
, Stem: A postoperative client rates pain 8/10 two hours after
surgery. The nurse’s planned interventions include position
change, guided imagery, and PRN opioid per MD order. Which
intervention is an independent nursing action?
A. Administer PRN opioid.
B. Teach and assist with guided imagery.
C. Call the surgeon for a new analgesic order.
D. Document pain as “patient reports pain 8/10.”
Correct answer: B
Rationales — Correct: Guided imagery is a nonpharmacologic,
independent nursing intervention the nurse can implement
immediately to reduce pain perception.
Incorrect: A is dependent — requires prescriber’s order. C is
collaborative/dependent and not an immediate independent
action. D is documentation (required) but not an intervention to
relieve pain.
Teaching Point: Distinguish independent nonpharmacologic
interventions from dependent medication actions.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing diagnosis
section.
4
Reference: Ineffective Airway Clearance — Planning Client Care
(Nursing Process — Outcome Identification & Prioritization)
Stem: A client with pneumonia has coarse crackles and a
Diagnoses, Prioritized Interventions,
And Rationales
16th Edition
• Author(S)Marilynn E. Doenges; Mary
Frances Moorhouse; Alice C. Murr
TEST BANK
1
Reference: Knowledge Deficit — Planning Client Care (Nursing
Process — Outcome Identification & Planning)
Stem: A 55-year-old client newly diagnosed with type 2
diabetes says, “I don’t know how to manage my medicines or
what to eat.” The nurse is planning care. Which nursing
outcome is most appropriate for the initial plan of care?
A. Client will demonstrate correct insulin injection technique by
,discharge.
B. Client will state the pathophysiology of diabetes in own
words within 48 hours.
C. Client will verbalize fear and grief related to diagnosis within
24 hours.
D. Client’s blood glucose will remain within normal range
without medication.
Correct answer: A
Rationales — Correct: Option A is a specific, measurable,
attainable short-term outcome focused on self-management
skills (knowledge → skill) consistent with planning care for a
Knowledge Deficit. Skill demonstration is priority for safety.
Incorrect: B is overly cognitive and not directly safety-focused;
it’s less measurable for discharge teaching. C is an affective goal
(valid) but not highest priority for immediate self-care safety. D
is unrealistic and may be unsafe to promise; it conflates medical
management with nursing teaching.
Teaching Point: Prioritize measurable skill-based outcomes for
Knowledge Deficit affecting self-care.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing diagnosis
section.
2
Reference: Risk for Falls — Planning Client Care (Nursing
Process — Prioritization & Safety Outcomes)
,Stem: An 82-year-old post-op client is on bed rest, requesting
help to the bathroom. The nurse plans outcomes. Which
outcome is most appropriate and measurable?
A. Client will not fall during hospitalization.
B. Client will use call light before ambulating for the next 48
hours.
C. Client will ambulate independently to the bathroom by
tomorrow.
D. Client will maintain muscle strength.
Correct answer: B
Rationales — Correct: Option B is specific, measurable, and
directly targets a safety behavior (call light use) to reduce fall
risk — an immediate nursing-planning focus.
Incorrect: A is a “never” goal and not specific or measurable by
nursing interventions. C may be unsafe and unrealistic given
recent surgery and bed rest. D is vague and not measurable in
the short term.
Teaching Point: Use specific, observable behaviors (call light
use) for fall-prevention outcomes.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing diagnosis
section.
3
Reference: Acute Pain — Planning Client Care (Nursing Process
— Interventions: Independent vs. Collaborative)
, Stem: A postoperative client rates pain 8/10 two hours after
surgery. The nurse’s planned interventions include position
change, guided imagery, and PRN opioid per MD order. Which
intervention is an independent nursing action?
A. Administer PRN opioid.
B. Teach and assist with guided imagery.
C. Call the surgeon for a new analgesic order.
D. Document pain as “patient reports pain 8/10.”
Correct answer: B
Rationales — Correct: Guided imagery is a nonpharmacologic,
independent nursing intervention the nurse can implement
immediately to reduce pain perception.
Incorrect: A is dependent — requires prescriber’s order. C is
collaborative/dependent and not an immediate independent
action. D is documentation (required) but not an intervention to
relieve pain.
Teaching Point: Distinguish independent nonpharmacologic
interventions from dependent medication actions.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing diagnosis
section.
4
Reference: Ineffective Airway Clearance — Planning Client Care
(Nursing Process — Outcome Identification & Prioritization)
Stem: A client with pneumonia has coarse crackles and a
