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 — Developing Measurable Desired Outcomes
(Chapter 1)
Stem
A 68-year-old postoperative patient is weak and reports, “I can’t
walk to the bathroom without help.” The nurse writes the
expected outcome: “Patient will ambulate to bathroom
,independently.” Which problem is most likely present and
which revision to the outcome best follows the textbook
guidance for measurable outcomes?
A. Activity Intolerance; revise to “Patient will ambulate 50 feet
to bathroom with a walker by discharge.”
B. Risk for Injury; revise to “Patient will not fall.”
C. Impaired Physical Mobility; revise to “Patient will ambulate to
bathroom this evening.”
D. Self-Care Deficit; revise to “Patient will request help when
needed.”
Correct answer: A
Rationale — Correct (A)
Chapter 1 emphasizes writing measurable, observable, and
time-limited outcomes. A postoperative patient reporting
inability to walk suggests Activity Intolerance or Impaired
Physical Mobility; the revised outcome specifying distance, use
of assistive device, and time frame is measurable and goal-
directed. This follows the book’s guidance to make outcomes
specific and quantifiable.
Rationale — Incorrect
B. “Risk for Injury” and “will not fall” are vague and
unmeasurable; “will not fall” is a nursing aim but not a
measurable outcome.
C. “Ambulate to bathroom this evening” lacks distance,
assistance level, and measurable criteria.
,D. “Request help when needed” is behavioral but not specific,
measurable, nor time-limited.
Teaching point:
Make outcomes specific, measurable, use condition/device, and
time frame.
Citation:
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse’s
Pocket Guide (16th ed.). Nursing process and planning client
care section.
2
Reference
Assessment → Diagnostic Statement Construction (Chapter 1)
Stem
A client has dyspnea, oxygen saturation 88% on room air, and
shortness of breath while speaking. Which nursing diagnostic
statement written per the textbook best reflects accurate
diagnostic construction?
A. Impaired Gas Exchange related to pulmonary disease as
evidenced by SpO₂ 88% and dyspnea.
B. Impaired Gas Exchange related to hypoxemia.
C. Activity Intolerance related to low oxygen saturation.
D. Ineffective Airway Clearance related to dyspnea.
Correct answer: A
, Rationale — Correct (A)
Chapter 1 shows diagnostic statements should include
diagnosis, related (etiologic) factor, and defining characteristics
(“evidenced by”). Option A supplies the diagnosis, a plausible
related factor, and objective evidence (SpO₂ 88% and dyspnea),
matching textbook structure.
Rationale — Incorrect
B. “Related to hypoxemia” is circular and lacks specific cause;
also lacks sufficient defining characteristics.
C. Activity Intolerance may be present but the defining
characteristics point most directly to Impaired Gas Exchange.
D. Ineffective Airway Clearance implies secretions/obstruction;
dyspnea and low SpO₂ better support gas-exchange problem.
Teaching point:
Include diagnosis + related factor + defining characteristics in
one diagnostic statement.
Citation:
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse’s
Pocket Guide (16th ed.). Nursing process and planning client
care section.
3
Reference
Prioritizing Nursing Diagnoses — Use of ABCs and Maslow
(Chapter 1)
Diagnoses, Prioritized Interventions,
And Rationales
16th Edition
• Author(S)Marilynn E. Doenges; Mary
Frances Moorhouse; Alice C. Murr
TEST BANK
1
Reference
Nursing Process — Developing Measurable Desired Outcomes
(Chapter 1)
Stem
A 68-year-old postoperative patient is weak and reports, “I can’t
walk to the bathroom without help.” The nurse writes the
expected outcome: “Patient will ambulate to bathroom
,independently.” Which problem is most likely present and
which revision to the outcome best follows the textbook
guidance for measurable outcomes?
A. Activity Intolerance; revise to “Patient will ambulate 50 feet
to bathroom with a walker by discharge.”
B. Risk for Injury; revise to “Patient will not fall.”
C. Impaired Physical Mobility; revise to “Patient will ambulate to
bathroom this evening.”
D. Self-Care Deficit; revise to “Patient will request help when
needed.”
Correct answer: A
Rationale — Correct (A)
Chapter 1 emphasizes writing measurable, observable, and
time-limited outcomes. A postoperative patient reporting
inability to walk suggests Activity Intolerance or Impaired
Physical Mobility; the revised outcome specifying distance, use
of assistive device, and time frame is measurable and goal-
directed. This follows the book’s guidance to make outcomes
specific and quantifiable.
Rationale — Incorrect
B. “Risk for Injury” and “will not fall” are vague and
unmeasurable; “will not fall” is a nursing aim but not a
measurable outcome.
C. “Ambulate to bathroom this evening” lacks distance,
assistance level, and measurable criteria.
,D. “Request help when needed” is behavioral but not specific,
measurable, nor time-limited.
Teaching point:
Make outcomes specific, measurable, use condition/device, and
time frame.
Citation:
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse’s
Pocket Guide (16th ed.). Nursing process and planning client
care section.
2
Reference
Assessment → Diagnostic Statement Construction (Chapter 1)
Stem
A client has dyspnea, oxygen saturation 88% on room air, and
shortness of breath while speaking. Which nursing diagnostic
statement written per the textbook best reflects accurate
diagnostic construction?
A. Impaired Gas Exchange related to pulmonary disease as
evidenced by SpO₂ 88% and dyspnea.
B. Impaired Gas Exchange related to hypoxemia.
C. Activity Intolerance related to low oxygen saturation.
D. Ineffective Airway Clearance related to dyspnea.
Correct answer: A
, Rationale — Correct (A)
Chapter 1 shows diagnostic statements should include
diagnosis, related (etiologic) factor, and defining characteristics
(“evidenced by”). Option A supplies the diagnosis, a plausible
related factor, and objective evidence (SpO₂ 88% and dyspnea),
matching textbook structure.
Rationale — Incorrect
B. “Related to hypoxemia” is circular and lacks specific cause;
also lacks sufficient defining characteristics.
C. Activity Intolerance may be present but the defining
characteristics point most directly to Impaired Gas Exchange.
D. Ineffective Airway Clearance implies secretions/obstruction;
dyspnea and low SpO₂ better support gas-exchange problem.
Teaching point:
Include diagnosis + related factor + defining characteristics in
one diagnostic statement.
Citation:
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse’s
Pocket Guide (16th ed.). Nursing process and planning client
care section.
3
Reference
Prioritizing Nursing Diagnoses — Use of ABCs and Maslow
(Chapter 1)
