Correct Answer: B

Rationale: The correct answer is B because subjective data in a nursing assessment refers to information provided by the patient, such as feelings, perceptions, and symptoms. In this case, the client stating 'I feel nauseated' represents subjective data. This type of information cannot be measured or observed directly. A, C, and D are incorrect: A: Heart rate of 90 beats per minute is an objective measurement that can be directly observed. C: Blood pressure of 130/80 mmHg is also an objective measurement that can be directly observed. D: Skin appears flushed is an objective observation that can be directly seen.

Correct Answer: B

Rationale: The correct answer is B: Focus on the patient's presenting situation. In the problem-oriented approach, the nurse starts by gathering data related to the patient's current health issue or concern. This step is crucial as it helps identify the primary problem and sets the direction for further data collection and analysis. By focusing on the patient's presenting situation, the nurse can prioritize information gathering and make informed decisions about the next steps in care. Incorrect choices: A: Completing questions in chronological order may not be relevant to the patient's current issue and could lead to missing important details. C: Making accurate interpretations of the data comes after data collection, so it is not the first step. D: Conducting an observational overview is important but typically follows focusing on the presenting situation to gather specific information.

Correct Answer: D

Rationale: The correct answer is D: Pallor, tachycardia, and a sore tongue. Pernicious anemia is caused by a deficiency in vitamin B12, leading to symptoms such as pallor (due to decreased red blood cells), tachycardia (as the heart works harder to compensate for decreased oxygen-carrying capacity of the blood), and a sore tongue (due to inflammation of the tongue). Choice A is incorrect because bradycardia would not be expected in pernicious anemia, and reduced pulse is not a typical finding. Choice B is incorrect because weight gain is not a common symptom of pernicious anemia. Choice C is incorrect because angina and double vision are not typical findings of pernicious anemia, and anorexia is more likely due to other causes.

Correct Answer: B

Rationale: Rationale for Correct Answer B: Rehabilitation plans for Mr. Gabatan should be considered and planned for early in his care to optimize his recovery and quality of life. Planning early allows for tailored interventions to address his specific needs and goals, promoting better outcomes. Early rehabilitation can also prevent complications and improve functional abilities. By proactively addressing rehabilitation needs, Mr. Gabatan can have a smoother transition back to his daily activities. Summary of Incorrect Choices: A: Leaving the rehabilitation plans solely up to Mr. Gabatan and his family may not consider all aspects of his recovery and could lead to suboptimal outcomes. C: Assuming that Mr. Gabatan will return to his former activities without a rehabilitation plan overlooks the individualized care needed for his recovery. D: Dismissing the need for rehabilitation based on the assumption that he may not be able to work again is premature and does not account for potential improvements in his condition through appropriate rehabilitation interventions.

Correct Answer: D

Rationale: The correct answer is D because developing a standard formal nursing diagnosis helps nurses focus on their scope of practice, which involves identifying and addressing the patient's nursing care needs. By formulating a specific nursing diagnosis, nurses can prioritize interventions and provide individualized care. Choice A is incorrect as nursing diagnoses are not exclusive to nurses. Choice B is incorrect because nursing and physician roles overlap. Choice C is incorrect as clinical judgment should be based on evidence and critical thinking, not solely on intuition.