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 — Assessment: Subjective vs. Objective
Data
Stem
A 68-year-old postoperative client reports “I feel weak and
dizzy” and you note a blood pressure of 86/54 mm Hg and pale,
,cool skin. Which data should a nurse document as subjective,
and which supports immediate priority action?
A. “I feel weak and dizzy” — subjective; low BP supports
immediate action.
B. Pale, cool skin — subjective; BP supports immediate action.
C. Blood pressure 86/54 mm Hg — subjective; client complaint
supports immediate action.
D. Pale, cool skin — objective; client complaint is not useful for
immediate action.
Correct answer: A
Rationales
Correct (A): “I feel weak and dizzy” is a subjective report
(client’s own words); blood pressure 86/54 mm Hg is objective,
measurable data that explains the complaint and requires
immediate priority action for perfusion. This distinction aligns
with chapter guidance on subjective (verbal) versus objective
(observable/measurable) data and using both to set priorities.
Incorrect (B): Pale, cool skin is objective, not subjective. While it
supports urgent action, the option mislabels the cue.
Incorrect (C): BP is an objective finding, not subjective. The
client’s complaint adds context but objective hypotension is the
immediate physiological cue.
Incorrect (D): The client complaint is useful—subjective data
help interpret objective findings and guide interventions.
Teaching point: Subjective = patient-reported; objective =
observed/measured; both guide priority action.
,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
The Nursing Process — Five Steps and Their Sequence
Stem
A new graduate nurse prepares a care plan. Which sequence
best reflects the nursing process as presented in Chapter 1?
A. Implementation → Assessment → Diagnosis → Evaluation →
Planning
B. Assessment → Diagnosis → Planning → Implementation →
Evaluation
C. Diagnosis → Assessment → Planning → Implementation →
Evaluation
D. Assessment → Planning → Diagnosis → Implementation →
Evaluation
Correct answer: B
Rationales
Correct (B): Chapter 1 defines the five sequential steps as
assessment, diagnosis, planning, implementation, and
evaluation—this order supports systematic clinical reasoning
and documentation.
Incorrect (A): Implementation cannot precede assessment and
, diagnosis; doing so risks unsafe, non-individualized care.
Incorrect (C): Diagnosis requires data from assessment;
reversing them is illogical.
Incorrect (D): Planning requires the diagnostic statement that
results from assessment; diagnosis must come before planning.
Teaching point: Follow ADPIE: Assess → Diagnose → Plan →
Implement → Evaluate.
Citation: Doenges et al. (2022). Chapter 1.
3
Reference
Data Analysis and Diagnostic Statement Construction (PES
format)
Stem
A client has poor glucose monitoring, missed insulin doses, and
frequent fasting blood glucose readings >250 mg/dL. According
to Chapter 1 guidance on diagnostic statements, which PES-
style nursing diagnostic statement is best?
A. Risk for unstable blood glucose level related to missed
injections.
B. Unstable blood glucose level as evidenced by fasting blood
glucose >250 mg/dL.
C. Risk for unstable blood glucose level as evidenced by missed
doses and poor monitoring.
D. Risk for unstable blood glucose level related to inadequate
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 — Assessment: Subjective vs. Objective
Data
Stem
A 68-year-old postoperative client reports “I feel weak and
dizzy” and you note a blood pressure of 86/54 mm Hg and pale,
,cool skin. Which data should a nurse document as subjective,
and which supports immediate priority action?
A. “I feel weak and dizzy” — subjective; low BP supports
immediate action.
B. Pale, cool skin — subjective; BP supports immediate action.
C. Blood pressure 86/54 mm Hg — subjective; client complaint
supports immediate action.
D. Pale, cool skin — objective; client complaint is not useful for
immediate action.
Correct answer: A
Rationales
Correct (A): “I feel weak and dizzy” is a subjective report
(client’s own words); blood pressure 86/54 mm Hg is objective,
measurable data that explains the complaint and requires
immediate priority action for perfusion. This distinction aligns
with chapter guidance on subjective (verbal) versus objective
(observable/measurable) data and using both to set priorities.
Incorrect (B): Pale, cool skin is objective, not subjective. While it
supports urgent action, the option mislabels the cue.
Incorrect (C): BP is an objective finding, not subjective. The
client’s complaint adds context but objective hypotension is the
immediate physiological cue.
Incorrect (D): The client complaint is useful—subjective data
help interpret objective findings and guide interventions.
Teaching point: Subjective = patient-reported; objective =
observed/measured; both guide priority action.
,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
The Nursing Process — Five Steps and Their Sequence
Stem
A new graduate nurse prepares a care plan. Which sequence
best reflects the nursing process as presented in Chapter 1?
A. Implementation → Assessment → Diagnosis → Evaluation →
Planning
B. Assessment → Diagnosis → Planning → Implementation →
Evaluation
C. Diagnosis → Assessment → Planning → Implementation →
Evaluation
D. Assessment → Planning → Diagnosis → Implementation →
Evaluation
Correct answer: B
Rationales
Correct (B): Chapter 1 defines the five sequential steps as
assessment, diagnosis, planning, implementation, and
evaluation—this order supports systematic clinical reasoning
and documentation.
Incorrect (A): Implementation cannot precede assessment and
, diagnosis; doing so risks unsafe, non-individualized care.
Incorrect (C): Diagnosis requires data from assessment;
reversing them is illogical.
Incorrect (D): Planning requires the diagnostic statement that
results from assessment; diagnosis must come before planning.
Teaching point: Follow ADPIE: Assess → Diagnose → Plan →
Implement → Evaluate.
Citation: Doenges et al. (2022). Chapter 1.
3
Reference
Data Analysis and Diagnostic Statement Construction (PES
format)
Stem
A client has poor glucose monitoring, missed insulin doses, and
frequent fasting blood glucose readings >250 mg/dL. According
to Chapter 1 guidance on diagnostic statements, which PES-
style nursing diagnostic statement is best?
A. Risk for unstable blood glucose level related to missed
injections.
B. Unstable blood glucose level as evidenced by fasting blood
glucose >250 mg/dL.
C. Risk for unstable blood glucose level as evidenced by missed
doses and poor monitoring.
D. Risk for unstable blood glucose level related to inadequate
