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 →
Diagnosis → Planning.
Stem
A postoperative client 8 hours after abdominal surgery reports
increasing abdominal pain rated 8/10, has a blood pressure of
88/56 mmHg, pulse 120 bpm, cool, pale skin, and decreased
,urine output (20 mL/hr). Which nursing action most
appropriately reflects the first step in the nursing process for
this client?
A. Formulate the immediate nursing diagnosis.
B. Implement pain medication per standing order.
C. Perform rapid focused assessment and notify the surgeon.
D. Begin discharge teaching about activity restrictions.
Correct answer
C
Rationales
Correct (C): Chapter 1 emphasizes that assessment is the first
and priority step of the nursing process; a rapid focused
assessment identifies life-threatening changes (hypotension,
tachycardia, oliguria) and guides immediate communication
with the surgical team. Doenges et al. identify timely focused
reassessment and reporting as priority when findings suggest
compromise.
A: Formulating a diagnosis before completing assessment risks
mislabeling the client’s problem; diagnosis follows data
collection.
B: Implementing analgesia may be appropriate but should
follow assessment for hemodynamic stability and orders; pain
meds alone ignore hypotension and tachycardia.
D: Discharge teaching is inappropriate and low priority given
current instability.
,Teaching point
Always assess first; prioritize focused reassessment when vital
signs indicate instability.
Citation
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse’s
Pocket Guide (16th ed.). Chapter 1: The Nursing Process and
Planning Client Care.
2
Reference
The Nursing Process and Planning Client Care — Data Clustering
& Diagnostic Reasoning.
Stem
A 68-year-old client has the following data: confusion, slurred
speech, right-sided facial droop, right-sided weakness, and
elevated blood pressure. When clustering assessment data to
identify a nursing diagnosis, which cluster indicates the priority
problem?
A. Confusion, slurred speech, facial droop (neurologic deficit
cluster).
B. Elevated blood pressure and age (risk factor cluster).
C. Right-sided weakness and facial droop (mobility cluster).
D. Confusion and age (cognitive decline cluster).
Correct answer
A
, Rationales
Correct (A): Chapter 1 stresses clustering related assessment
cues to form diagnostic inferences; the neurologic deficit cluster
(confusion, slurred speech, facial droop) suggests an acute
cerebrovascular event requiring immediate action. This cluster
directs priority nursing diagnoses and interventions.
B: Elevated BP is an important risk factor but alone does not
represent the primary clustered problem.
C: Mobility cluster is narrower; the neurologic cluster more
comprehensively captures the acute event.
D: Age with confusion is nonspecific and risks missing acute
neurologic change.
Teaching point
Cluster related cues (signs/symptoms) to identify the most likely
and urgent nursing problem.
Citation
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse’s
Pocket Guide (16th ed.). Chapter 1: The Nursing Process and
Planning Client Care.
3
Reference
The Nursing Process and Planning Client Care — Actual vs Risk
Nursing Diagnoses.
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 →
Diagnosis → Planning.
Stem
A postoperative client 8 hours after abdominal surgery reports
increasing abdominal pain rated 8/10, has a blood pressure of
88/56 mmHg, pulse 120 bpm, cool, pale skin, and decreased
,urine output (20 mL/hr). Which nursing action most
appropriately reflects the first step in the nursing process for
this client?
A. Formulate the immediate nursing diagnosis.
B. Implement pain medication per standing order.
C. Perform rapid focused assessment and notify the surgeon.
D. Begin discharge teaching about activity restrictions.
Correct answer
C
Rationales
Correct (C): Chapter 1 emphasizes that assessment is the first
and priority step of the nursing process; a rapid focused
assessment identifies life-threatening changes (hypotension,
tachycardia, oliguria) and guides immediate communication
with the surgical team. Doenges et al. identify timely focused
reassessment and reporting as priority when findings suggest
compromise.
A: Formulating a diagnosis before completing assessment risks
mislabeling the client’s problem; diagnosis follows data
collection.
B: Implementing analgesia may be appropriate but should
follow assessment for hemodynamic stability and orders; pain
meds alone ignore hypotension and tachycardia.
D: Discharge teaching is inappropriate and low priority given
current instability.
,Teaching point
Always assess first; prioritize focused reassessment when vital
signs indicate instability.
Citation
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse’s
Pocket Guide (16th ed.). Chapter 1: The Nursing Process and
Planning Client Care.
2
Reference
The Nursing Process and Planning Client Care — Data Clustering
& Diagnostic Reasoning.
Stem
A 68-year-old client has the following data: confusion, slurred
speech, right-sided facial droop, right-sided weakness, and
elevated blood pressure. When clustering assessment data to
identify a nursing diagnosis, which cluster indicates the priority
problem?
A. Confusion, slurred speech, facial droop (neurologic deficit
cluster).
B. Elevated blood pressure and age (risk factor cluster).
C. Right-sided weakness and facial droop (mobility cluster).
D. Confusion and age (cognitive decline cluster).
Correct answer
A
, Rationales
Correct (A): Chapter 1 stresses clustering related assessment
cues to form diagnostic inferences; the neurologic deficit cluster
(confusion, slurred speech, facial droop) suggests an acute
cerebrovascular event requiring immediate action. This cluster
directs priority nursing diagnoses and interventions.
B: Elevated BP is an important risk factor but alone does not
represent the primary clustered problem.
C: Mobility cluster is narrower; the neurologic cluster more
comprehensively captures the acute event.
D: Age with confusion is nonspecific and risks missing acute
neurologic change.
Teaching point
Cluster related cues (signs/symptoms) to identify the most likely
and urgent nursing problem.
Citation
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse’s
Pocket Guide (16th ed.). Chapter 1: The Nursing Process and
Planning Client Care.
3
Reference
The Nursing Process and Planning Client Care — Actual vs Risk
Nursing Diagnoses.
