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 & Data Collection
(Chapter 1: The Nursing Process and Planning Client Care)
Stem: A 68-year-old patient with chronic heart failure reports
increasing dyspnea at rest and orthopnea. On assessment you
note bilateral crackles, 3+ pitting edema of lower extremities,
and oxygen saturation 88% on room air. Which nursing
diagnosis is best supported by these data?
,A. Fluid Volume Deficit
B. Impaired Gas Exchange
C. Ineffective Tissue Perfusion
D. Activity Intolerance
Correct Answer: B
Rationales:
• Correct (B): The combination of dyspnea, orthopnea,
bilateral crackles, and low SpO₂ indicates inadequate
oxygenation at the alveolar-capillary level consistent with
Impaired Gas Exchange. These are primary assessment
cues used to form a gas-exchange diagnosis per chapter
guidance on clustering data.
• Incorrect (A): Fluid Volume Deficit is inconsistent with
edema and signs of fluid overload. Choosing this reverses
the key assessment cluster.
• Incorrect (C): Ineffective Tissue Perfusion focuses on
localized perfusion (e.g., diminished pulses, ischemic pain);
the findings indicate respiratory oxygenation problems
rather than peripheral perfusion.
• Incorrect (D): Activity Intolerance may be present but is a
related problem secondary to impaired gas exchange; it is
not the primary diagnosis with current oxygenation
impairment.
Teaching Point: Cluster respiratory signs (dyspnea, crackles, low
SpO₂) to prioritize impaired gas exchange.
,Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing diagnosis
section.
2
Reference: Nursing Process — Diagnosis Writing & NANDA
Language (Chapter 1: The Nursing Process and Planning Client
Care)
Stem: A nurse must write a problem-focused nursing diagnosis
for a postoperative patient with shallow respirations and
decreased breath sounds in the left lower lobe. Which is the
best example of a properly formatted NANDA diagnosis?
A. Pneumonia related to anesthesia as evidenced by shallow
respirations
B. Ineffective Airway Clearance related to retained secretions as
evidenced by shallow respirations and decreased left lower lobe
breath sounds
C. Respiratory problem — shallow respirations
D. Impaired lung function due to secretions
Correct Answer: B
Rationales:
• Correct (B): This option follows the NANDA-format:
diagnostic label (Ineffective Airway Clearance), related
factor (retained secretions), and defining characteristics
, (shallow respirations, decreased breath sounds). Chapter 1
emphasizes clear, three-part phrasing for accuracy.
• Incorrect (A): Uses a medical diagnosis (pneumonia) and
misses specific defining characteristics and proper nursing-
label format. Nursing diagnoses should not restate medical
diagnoses.
• Incorrect (C): Vague and lacks a proper NANDA nursing
diagnosis label and related/rationale components—
insufficient for care planning.
• Incorrect (D): Nonstandard wording; not a recognized
NANDA label and omits defining characteristics and related
factors.
Teaching Point: Use the three-part NANDA format: label —
related factor — defining characteristics.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing diagnosis
section.
3
Reference: Nursing Process — Outcome Writing (Chapter 1: The
Nursing Process and Planning Client Care)
Stem: For a patient diagnosed with Risk for Falls, which
outcome statement represents the most appropriate,
measurable short-term outcome for discharge planning?
A. Patient will not fall.
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 & Data Collection
(Chapter 1: The Nursing Process and Planning Client Care)
Stem: A 68-year-old patient with chronic heart failure reports
increasing dyspnea at rest and orthopnea. On assessment you
note bilateral crackles, 3+ pitting edema of lower extremities,
and oxygen saturation 88% on room air. Which nursing
diagnosis is best supported by these data?
,A. Fluid Volume Deficit
B. Impaired Gas Exchange
C. Ineffective Tissue Perfusion
D. Activity Intolerance
Correct Answer: B
Rationales:
• Correct (B): The combination of dyspnea, orthopnea,
bilateral crackles, and low SpO₂ indicates inadequate
oxygenation at the alveolar-capillary level consistent with
Impaired Gas Exchange. These are primary assessment
cues used to form a gas-exchange diagnosis per chapter
guidance on clustering data.
• Incorrect (A): Fluid Volume Deficit is inconsistent with
edema and signs of fluid overload. Choosing this reverses
the key assessment cluster.
• Incorrect (C): Ineffective Tissue Perfusion focuses on
localized perfusion (e.g., diminished pulses, ischemic pain);
the findings indicate respiratory oxygenation problems
rather than peripheral perfusion.
• Incorrect (D): Activity Intolerance may be present but is a
related problem secondary to impaired gas exchange; it is
not the primary diagnosis with current oxygenation
impairment.
Teaching Point: Cluster respiratory signs (dyspnea, crackles, low
SpO₂) to prioritize impaired gas exchange.
,Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing diagnosis
section.
2
Reference: Nursing Process — Diagnosis Writing & NANDA
Language (Chapter 1: The Nursing Process and Planning Client
Care)
Stem: A nurse must write a problem-focused nursing diagnosis
for a postoperative patient with shallow respirations and
decreased breath sounds in the left lower lobe. Which is the
best example of a properly formatted NANDA diagnosis?
A. Pneumonia related to anesthesia as evidenced by shallow
respirations
B. Ineffective Airway Clearance related to retained secretions as
evidenced by shallow respirations and decreased left lower lobe
breath sounds
C. Respiratory problem — shallow respirations
D. Impaired lung function due to secretions
Correct Answer: B
Rationales:
• Correct (B): This option follows the NANDA-format:
diagnostic label (Ineffective Airway Clearance), related
factor (retained secretions), and defining characteristics
, (shallow respirations, decreased breath sounds). Chapter 1
emphasizes clear, three-part phrasing for accuracy.
• Incorrect (A): Uses a medical diagnosis (pneumonia) and
misses specific defining characteristics and proper nursing-
label format. Nursing diagnoses should not restate medical
diagnoses.
• Incorrect (C): Vague and lacks a proper NANDA nursing
diagnosis label and related/rationale components—
insufficient for care planning.
• Incorrect (D): Nonstandard wording; not a recognized
NANDA label and omits defining characteristics and related
factors.
Teaching Point: Use the three-part NANDA format: label —
related factor — defining characteristics.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing diagnosis
section.
3
Reference: Nursing Process — Outcome Writing (Chapter 1: The
Nursing Process and Planning Client Care)
Stem: For a patient diagnosed with Risk for Falls, which
outcome statement represents the most appropriate,
measurable short-term outcome for discharge planning?
A. Patient will not fall.
