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
— Data Collection & Diagnostic Clustering (Chapter 1)
Stem: A 68-year-old postoperative client has dyspnea,
SpO₂ 88% on room air, crackles heard bilaterally, and
reports "I can't breathe." The nurse prepares to cluster
assessment data to choose a nursing diagnosis. Which
clustering best supports selecting Impaired Gas Exchange
as the nursing diagnosis?
A. Shortness of breath + reports of pain + delayed capillary
, refill
B. Dyspnea + SpO₂ 88% + bilateral crackles + anxious affect
C. Postoperative incision site intact + afebrile + ambulating
with assistance
D. Urinary output 40 mL/hr + soft abdomen + tolerating
diet
Correct answer: B
Rationale — Correct: Clustering objective (SpO₂ 88%,
bilateral crackles) and subjective (dyspnea, anxious affect)
mirrors the defining characteristics of Impaired Gas
Exchange and guides diagnosis selection. Chapter 1
emphasizes organizing assessment cues into meaningful
clusters to validate a nursing diagnosis.
Rationale — Incorrect: A contains pain and capillary refill
unrelated to gas exchange primary cues. C and D contain
findings unrelated to gas exchange; they may suggest
other problems or are normal.
Teaching point: Cluster respiratory signs and symptoms
(subjective + objective) to validate respiratory diagnoses.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing process
section.
2. Reference: The Nursing Process and Planning Client Care
— Diagnostic Statement Components (Chapter 1)
Stem: A student writes the nursing diagnostic statement:
, Ineffective airway clearance related to retained secretions
as evidenced by wheezing and productive cough. Which
component of the diagnostic statement is the phrase “as
evidenced by wheezing and productive cough”?
A. Related/risk factors
B. Diagnostic label
C. Defining characteristics (evidence)
D. Outcome criteria
Correct answer: C
Rationale — Correct: The phrase lists the defining
characteristics (subjective/objective evidence) that support
the diagnosis; Chapter 1 explains diagnostic statements
include defining characteristics as “evidenced by.”
Rationale — Incorrect: A (related factors) would be the
“related to” clause; B is the diagnostic label itself; D
(outcome criteria) are measurable goals, not defining
characteristics.
Teaching point: “Evidenced by” = defining characteristics
supporting the diagnosis.
Citation: Doenges et al. (2022). Nurse’s Pocket Guide (16th
ed.).
3. Reference: The Nursing Process — Prioritizing Diagnoses
(Chapter 1)
Stem: A client has three nursing diagnoses: Risk for Falls,
Ineffective Breathing Pattern, and Anxiety. The client is
, currently experiencing marked respiratory distress.
According to priority-setting principles in Chapter 1, which
diagnosis should the nurse address first?
A. Risk for Falls
B. Anxiety
C. Ineffective Breathing Pattern
D. All have equal priority and should be addressed
simultaneously
Correct answer: C
Rationale — Correct: Chapter 1 emphasizes priority setting
using ABCs (airway/ breathing/ circulation); a breathing
problem is life-threatening and highest priority.
Rationale — Incorrect: A and B are important but lower
priority when breathing is compromised. D is incorrect
because priorities must be sequenced based on risk and
immediacy.
Teaching point: Use ABCs to prioritize — airway/breathing
problems come first.
Citation: Doenges et al. (2022). Nurse’s Pocket Guide (16th
ed.).
4. Reference: The Nursing Process — Goal/Outcome Writing
(Chapter 1)
Stem: For a client with Impaired Skin Integrity related to
immobility, which outcome statement best reflects the
chapter’s guidance for measurable desired 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
— Data Collection & Diagnostic Clustering (Chapter 1)
Stem: A 68-year-old postoperative client has dyspnea,
SpO₂ 88% on room air, crackles heard bilaterally, and
reports "I can't breathe." The nurse prepares to cluster
assessment data to choose a nursing diagnosis. Which
clustering best supports selecting Impaired Gas Exchange
as the nursing diagnosis?
A. Shortness of breath + reports of pain + delayed capillary
, refill
B. Dyspnea + SpO₂ 88% + bilateral crackles + anxious affect
C. Postoperative incision site intact + afebrile + ambulating
with assistance
D. Urinary output 40 mL/hr + soft abdomen + tolerating
diet
Correct answer: B
Rationale — Correct: Clustering objective (SpO₂ 88%,
bilateral crackles) and subjective (dyspnea, anxious affect)
mirrors the defining characteristics of Impaired Gas
Exchange and guides diagnosis selection. Chapter 1
emphasizes organizing assessment cues into meaningful
clusters to validate a nursing diagnosis.
Rationale — Incorrect: A contains pain and capillary refill
unrelated to gas exchange primary cues. C and D contain
findings unrelated to gas exchange; they may suggest
other problems or are normal.
Teaching point: Cluster respiratory signs and symptoms
(subjective + objective) to validate respiratory diagnoses.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing process
section.
2. Reference: The Nursing Process and Planning Client Care
— Diagnostic Statement Components (Chapter 1)
Stem: A student writes the nursing diagnostic statement:
, Ineffective airway clearance related to retained secretions
as evidenced by wheezing and productive cough. Which
component of the diagnostic statement is the phrase “as
evidenced by wheezing and productive cough”?
A. Related/risk factors
B. Diagnostic label
C. Defining characteristics (evidence)
D. Outcome criteria
Correct answer: C
Rationale — Correct: The phrase lists the defining
characteristics (subjective/objective evidence) that support
the diagnosis; Chapter 1 explains diagnostic statements
include defining characteristics as “evidenced by.”
Rationale — Incorrect: A (related factors) would be the
“related to” clause; B is the diagnostic label itself; D
(outcome criteria) are measurable goals, not defining
characteristics.
Teaching point: “Evidenced by” = defining characteristics
supporting the diagnosis.
Citation: Doenges et al. (2022). Nurse’s Pocket Guide (16th
ed.).
3. Reference: The Nursing Process — Prioritizing Diagnoses
(Chapter 1)
Stem: A client has three nursing diagnoses: Risk for Falls,
Ineffective Breathing Pattern, and Anxiety. The client is
, currently experiencing marked respiratory distress.
According to priority-setting principles in Chapter 1, which
diagnosis should the nurse address first?
A. Risk for Falls
B. Anxiety
C. Ineffective Breathing Pattern
D. All have equal priority and should be addressed
simultaneously
Correct answer: C
Rationale — Correct: Chapter 1 emphasizes priority setting
using ABCs (airway/ breathing/ circulation); a breathing
problem is life-threatening and highest priority.
Rationale — Incorrect: A and B are important but lower
priority when breathing is compromised. D is incorrect
because priorities must be sequenced based on risk and
immediacy.
Teaching point: Use ABCs to prioritize — airway/breathing
problems come first.
Citation: Doenges et al. (2022). Nurse’s Pocket Guide (16th
ed.).
4. Reference: The Nursing Process — Goal/Outcome Writing
(Chapter 1)
Stem: For a client with Impaired Skin Integrity related to
immobility, which outcome statement best reflects the
chapter’s guidance for measurable desired outcomes?
