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 — Chapter 1: The Nursing Process and Planning
Client Care
Stem
A 68-year-old post-op hip replacement patient is 12 hours post-
op. Vital signs: T 37.6°C, HR 98, RR 20, SpO₂ 94% on 2 L NC. The
nurse notes the patient reports pain 7/10 at incision, limited
,mobility, and has shallow respirations. Which nursing diagnosis
statement best reflects correct diagnostic phrasing per the
Nurse’s Pocket Guide?
A. Acute pain related to surgery.
B. Acute pain related to tissue trauma as evidenced by patient
report of pain 7/10 and guarding.
C. Impaired physical mobility related to hip surgery.
D. Risk for ineffective breathing pattern related to post-op pain.
Correct answer
B
Rationale — Correct (B)
This option follows the textbook format for a diagnostic
statement: problem (Acute pain), related factor (tissue trauma),
and defining characteristics/evidence (patient report 7/10,
guarding). It is specific, links etiology to cues, and guides
targeted interventions. The Pocket Guide emphasizes including
“related to” and “as evidenced by” components where
appropriate to validate the diagnosis.
Rationale — Incorrect
A. Missing related/risk factor and defining characteristics; too
vague for individualized care planning.
C. Focuses on mobility but omits the primary cue cluster of pain
that needs immediate management.
D. States a risk diagnosis but provides objective evidence
(shallow respirations) that supports an actual rather than solely
risk diagnosis.
,Teaching point
Diagnostic statements should include problem, related factor,
and defining characteristics when present.
Citation
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse’s
Pocket Guide (16th ed.). Chapter 1.
2
Reference
Assessment & Data Collection — Chapter 1: The Nursing
Process and Planning Client Care
Stem
During admission assessment, a nurse documents the following:
recent weight loss of 6 kg in 4 weeks, poor appetite, dry skin,
and patient states “I feel tired all the time.” According to the
Pocket Guide’s guidance on assessment and data clustering,
what is the next best nursing action to prepare for accurate
diagnosis selection?
A. Select “Activity Intolerance” as the nursing diagnosis
immediately.
B. Cluster related assessment cues and obtain additional
focused data (sleep, bowel pattern, lab values).
C. Begin interventions for dehydration based on dry skin.
D. Refer to provider for immediate laboratory testing before
nursing diagnosis.
, Correct answer
B
Rationale — Correct (B)
Chapter 1 emphasizes systematic data collection and clustering
related cues to form a valid database that supports selecting an
appropriate nursing diagnosis. Focused follow-up questions and
targeted data (e.g., intake/output, labs) clarify the problem and
avoid premature conclusions.
Rationale — Incorrect
A. Jumping to a diagnosis without clustering and further
assessment is premature and may be incorrect.
C. Initiating interventions for dehydration may be appropriate
only after confirming assessment findings and relevance.
D. While collaboration may be necessary, nursing should first
cluster data and apply nursing-process reasoning rather than
immediately deferring.
Teaching point
Cluster assessment cues before selecting a nursing diagnosis;
gather targeted additional data as needed.
Citation
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse’s
Pocket Guide (16th ed.). Chapter 1.
3
Diagnoses, Prioritized Interventions,
And Rationales
16th Edition
• Author(S)Marilynn E. Doenges; Mary
Frances Moorhouse; Alice C. Murr
TEST BANK
1
Reference
Nursing Process — Chapter 1: The Nursing Process and Planning
Client Care
Stem
A 68-year-old post-op hip replacement patient is 12 hours post-
op. Vital signs: T 37.6°C, HR 98, RR 20, SpO₂ 94% on 2 L NC. The
nurse notes the patient reports pain 7/10 at incision, limited
,mobility, and has shallow respirations. Which nursing diagnosis
statement best reflects correct diagnostic phrasing per the
Nurse’s Pocket Guide?
A. Acute pain related to surgery.
B. Acute pain related to tissue trauma as evidenced by patient
report of pain 7/10 and guarding.
C. Impaired physical mobility related to hip surgery.
D. Risk for ineffective breathing pattern related to post-op pain.
Correct answer
B
Rationale — Correct (B)
This option follows the textbook format for a diagnostic
statement: problem (Acute pain), related factor (tissue trauma),
and defining characteristics/evidence (patient report 7/10,
guarding). It is specific, links etiology to cues, and guides
targeted interventions. The Pocket Guide emphasizes including
“related to” and “as evidenced by” components where
appropriate to validate the diagnosis.
Rationale — Incorrect
A. Missing related/risk factor and defining characteristics; too
vague for individualized care planning.
C. Focuses on mobility but omits the primary cue cluster of pain
that needs immediate management.
D. States a risk diagnosis but provides objective evidence
(shallow respirations) that supports an actual rather than solely
risk diagnosis.
,Teaching point
Diagnostic statements should include problem, related factor,
and defining characteristics when present.
Citation
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse’s
Pocket Guide (16th ed.). Chapter 1.
2
Reference
Assessment & Data Collection — Chapter 1: The Nursing
Process and Planning Client Care
Stem
During admission assessment, a nurse documents the following:
recent weight loss of 6 kg in 4 weeks, poor appetite, dry skin,
and patient states “I feel tired all the time.” According to the
Pocket Guide’s guidance on assessment and data clustering,
what is the next best nursing action to prepare for accurate
diagnosis selection?
A. Select “Activity Intolerance” as the nursing diagnosis
immediately.
B. Cluster related assessment cues and obtain additional
focused data (sleep, bowel pattern, lab values).
C. Begin interventions for dehydration based on dry skin.
D. Refer to provider for immediate laboratory testing before
nursing diagnosis.
, Correct answer
B
Rationale — Correct (B)
Chapter 1 emphasizes systematic data collection and clustering
related cues to form a valid database that supports selecting an
appropriate nursing diagnosis. Focused follow-up questions and
targeted data (e.g., intake/output, labs) clarify the problem and
avoid premature conclusions.
Rationale — Incorrect
A. Jumping to a diagnosis without clustering and further
assessment is premature and may be incorrect.
C. Initiating interventions for dehydration may be appropriate
only after confirming assessment findings and relevance.
D. While collaboration may be necessary, nursing should first
cluster data and apply nursing-process reasoning rather than
immediately deferring.
Teaching point
Cluster assessment cues before selecting a nursing diagnosis;
gather targeted additional data as needed.
Citation
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse’s
Pocket Guide (16th ed.). Chapter 1.
3
