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
MCQ 1
Reference
Nursing Process — Assessment & Data Collection
Stem
A nurse admits an older adult with acute shortness of breath
and anxiety. Assessment findings include RR 30/min, use of
accessory muscles, SpO₂ 89% on room air, and restlessness.
,Which nursing action is the priority during the assessment
phase?
Options
A. Ask about the client’s smoking history
B. Assess breath sounds and oxygen saturation
C. Obtain a detailed medication history
D. Evaluate sleep patterns over the past week
Correct Answer
B
Rationales
Correct (B): Immediate assessment of breath sounds and
oxygen saturation addresses airway and oxygenation, which are
the highest priorities during data collection. The Nurse’s Pocket
Guide emphasizes gathering data related to life-threatening
physiologic needs first.
Incorrect (A): Smoking history is relevant but does not address
the immediate respiratory compromise.
Incorrect (C): Medication history is important but secondary to
airway assessment.
Incorrect (D): Sleep patterns are not urgent in an acute
respiratory situation.
Teaching Point
Assess ABCs first when collecting data.
Citation
,Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse’s
Pocket Guide (16th ed.). Nursing process and planning client
care section.
MCQ 2
Reference
Nursing Process — Clustering Data for Diagnosis
Stem
A postoperative client reports incisional pain, has a temperature
of 38.3°C, elevated WBC count, and purulent drainage at the
incision site. Which nursing diagnosis statement is most
appropriate?
Options
A. Risk for Infection related to surgical incision
B. Acute Pain related to surgical procedure
C. Infection related to surgical wound as evidenced by fever and
purulent drainage
D. Impaired Tissue Integrity related to incision
Correct Answer
C
Rationales
Correct (C): The presence of defining characteristics (fever,
purulent drainage, leukocytosis) supports a problem-focused
, diagnosis rather than a risk diagnosis, consistent with diagnostic
reasoning guidance.
Incorrect (A): Risk diagnoses are inappropriate when signs and
symptoms are already present.
Incorrect (B): Pain exists but does not fully explain systemic
infectious indicators.
Incorrect (D): This diagnosis does not capture systemic infection
evidence.
Teaching Point
Use problem-focused diagnoses when defining characteristics
are present.
Citation
Doenges et al. (2022). Nurse’s Pocket Guide (16th ed.). Nursing
process section.
MCQ 3
Reference
Nursing Process — Writing Expected Outcomes
Stem
A nurse writes the following outcome for a client with impaired
mobility: “Client will improve ambulation.” Which revision best
reflects appropriate outcome criteria?
Options
Diagnoses, Prioritized Interventions,
And Rationales
16th Edition
• Author(S)Marilynn E. Doenges; Mary
Frances Moorhouse; Alice C. Murr
TEST BANK
MCQ 1
Reference
Nursing Process — Assessment & Data Collection
Stem
A nurse admits an older adult with acute shortness of breath
and anxiety. Assessment findings include RR 30/min, use of
accessory muscles, SpO₂ 89% on room air, and restlessness.
,Which nursing action is the priority during the assessment
phase?
Options
A. Ask about the client’s smoking history
B. Assess breath sounds and oxygen saturation
C. Obtain a detailed medication history
D. Evaluate sleep patterns over the past week
Correct Answer
B
Rationales
Correct (B): Immediate assessment of breath sounds and
oxygen saturation addresses airway and oxygenation, which are
the highest priorities during data collection. The Nurse’s Pocket
Guide emphasizes gathering data related to life-threatening
physiologic needs first.
Incorrect (A): Smoking history is relevant but does not address
the immediate respiratory compromise.
Incorrect (C): Medication history is important but secondary to
airway assessment.
Incorrect (D): Sleep patterns are not urgent in an acute
respiratory situation.
Teaching Point
Assess ABCs first when collecting data.
Citation
,Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse’s
Pocket Guide (16th ed.). Nursing process and planning client
care section.
MCQ 2
Reference
Nursing Process — Clustering Data for Diagnosis
Stem
A postoperative client reports incisional pain, has a temperature
of 38.3°C, elevated WBC count, and purulent drainage at the
incision site. Which nursing diagnosis statement is most
appropriate?
Options
A. Risk for Infection related to surgical incision
B. Acute Pain related to surgical procedure
C. Infection related to surgical wound as evidenced by fever and
purulent drainage
D. Impaired Tissue Integrity related to incision
Correct Answer
C
Rationales
Correct (C): The presence of defining characteristics (fever,
purulent drainage, leukocytosis) supports a problem-focused
, diagnosis rather than a risk diagnosis, consistent with diagnostic
reasoning guidance.
Incorrect (A): Risk diagnoses are inappropriate when signs and
symptoms are already present.
Incorrect (B): Pain exists but does not fully explain systemic
infectious indicators.
Incorrect (D): This diagnosis does not capture systemic infection
evidence.
Teaching Point
Use problem-focused diagnoses when defining characteristics
are present.
Citation
Doenges et al. (2022). Nurse’s Pocket Guide (16th ed.). Nursing
process section.
MCQ 3
Reference
Nursing Process — Writing Expected Outcomes
Stem
A nurse writes the following outcome for a client with impaired
mobility: “Client will improve ambulation.” Which revision best
reflects appropriate outcome criteria?
Options
