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: Subjective vs. Objective Data
Stem
A 68-year-old male admitted with shortness of breath reports “I
feel like I can’t get a deep breath.” Vital signs: RR 28/min, SpO₂
88% on room air, bilateral crackles on auscultation, peripheral
,edema +2. Which entry best represents a subjective cue for the
nursing database?
A. Respiratory rate 28/min.
B. Reports “I feel like I can’t get a deep breath.”
C. Oxygen saturation 88% on room air.
D. Bilateral crackles on lung auscultation.
Correct answer
B
Rationale — Correct
Patient statements are subjective data (what the client reports).
The nursing process separates subjective cues (symptoms) from
objective measurements to guide diagnosis and planning. This
cue indicates perceived dyspnea that needs correlation with
objective data.
Rationale — Incorrect
A. RR is objective (measurable).
C. SpO₂ is objective.
D. Auscultation finding is objective.
Teaching point
Subjective = client-reported symptoms; objective = measurable
signs.
Citation
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse’s
Pocket Guide (16th ed.). The Nursing Process and Planning
Client Care.
,2
Reference
Nursing Process — Data Collection: Primary and Secondary
Sources
Stem
A nurse admits an unconscious trauma patient. Which source of
data is the HIGHEST priority when forming the initial nursing
database?
A. Family history obtained by phone.
B. Current EMS report and paramedic notes.
C. Patient chart from previous hospitalization (2 years ago).
D. Statements from a neighbor at the scene.
Correct answer
B
Rationale — Correct
The primary priority is the most current, objective data about
the present event. EMS/paramedic report provides immediate,
accurate information about the event and prehospital
interventions and is essential for early diagnostic reasoning.
Rationale — Incorrect
A. Family data are useful but secondary and potentially delayed.
C. Prior chart is historical and may not reflect current status.
D. Neighbor statements may be incomplete and less reliable
than EMS records.
, Teaching point
Use the most current, direct sources (EMS, reports) for initial
assessment.
Citation
Doenges et al. (2022). Nurse’s Pocket Guide, Chapter 1.
3
Reference
Nursing Diagnosis Development — Cue Clustering & Pattern
Recognition
Stem
A client has fever 38.9°C, productive cough with green sputum,
elevated WBC, and pleuritic chest pain. Which best describes
the nurse’s next step for accurate diagnosis formation?
A. Select a nursing diagnosis immediately (e.g., Risk for
Infection).
B. Cluster related cues (fever, WBC, sputum, pain) and analyze
for a problem-focused diagnosis.
C. Ignore laboratory values and focus on the chief complaint
only.
D. Start all possible nursing interventions immediately without
diagnostic statement.
Correct answer
B
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: Subjective vs. Objective Data
Stem
A 68-year-old male admitted with shortness of breath reports “I
feel like I can’t get a deep breath.” Vital signs: RR 28/min, SpO₂
88% on room air, bilateral crackles on auscultation, peripheral
,edema +2. Which entry best represents a subjective cue for the
nursing database?
A. Respiratory rate 28/min.
B. Reports “I feel like I can’t get a deep breath.”
C. Oxygen saturation 88% on room air.
D. Bilateral crackles on lung auscultation.
Correct answer
B
Rationale — Correct
Patient statements are subjective data (what the client reports).
The nursing process separates subjective cues (symptoms) from
objective measurements to guide diagnosis and planning. This
cue indicates perceived dyspnea that needs correlation with
objective data.
Rationale — Incorrect
A. RR is objective (measurable).
C. SpO₂ is objective.
D. Auscultation finding is objective.
Teaching point
Subjective = client-reported symptoms; objective = measurable
signs.
Citation
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse’s
Pocket Guide (16th ed.). The Nursing Process and Planning
Client Care.
,2
Reference
Nursing Process — Data Collection: Primary and Secondary
Sources
Stem
A nurse admits an unconscious trauma patient. Which source of
data is the HIGHEST priority when forming the initial nursing
database?
A. Family history obtained by phone.
B. Current EMS report and paramedic notes.
C. Patient chart from previous hospitalization (2 years ago).
D. Statements from a neighbor at the scene.
Correct answer
B
Rationale — Correct
The primary priority is the most current, objective data about
the present event. EMS/paramedic report provides immediate,
accurate information about the event and prehospital
interventions and is essential for early diagnostic reasoning.
Rationale — Incorrect
A. Family data are useful but secondary and potentially delayed.
C. Prior chart is historical and may not reflect current status.
D. Neighbor statements may be incomplete and less reliable
than EMS records.
, Teaching point
Use the most current, direct sources (EMS, reports) for initial
assessment.
Citation
Doenges et al. (2022). Nurse’s Pocket Guide, Chapter 1.
3
Reference
Nursing Diagnosis Development — Cue Clustering & Pattern
Recognition
Stem
A client has fever 38.9°C, productive cough with green sputum,
elevated WBC, and pleuritic chest pain. Which best describes
the nurse’s next step for accurate diagnosis formation?
A. Select a nursing diagnosis immediately (e.g., Risk for
Infection).
B. Cluster related cues (fever, WBC, sputum, pain) and analyze
for a problem-focused diagnosis.
C. Ignore laboratory values and focus on the chief complaint
only.
D. Start all possible nursing interventions immediately without
diagnostic statement.
Correct answer
B
