the mother of a 2 year old tells the nurse that she is very concerned about her child because he has developed a will of his own and acts as if he can the mother of a 2 year old tells the nurse that she is very concerned about her child because he has developed a will of his own and acts as if he can
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NCLEX NCLEX-PN

2024 PN NCLEX Questions

1. According to Erikson, which developmental task is a toddler confronting when they develop 'a will of his own' and 'acts as if he can control others'?

Correct answer: Autonomy versus doubt and shame

Rationale: According to Erikson, the correct developmental task for a toddler who has developed 'a will of his own' and 'acts as if he can control others' is Autonomy versus doubt and shame. Toddlers at this stage are asserting their wills and realizing they can control others, which is part of developing autonomy. However, they may also experience doubt and shame if their assertiveness is met with disapproval. Trust versus mistrust is the developmental task of the infant, where the main focus is on developing trust in the caregiver. Initiative versus guilt is the developmental task of the preschool-age child, emphasizing the balance between taking initiative and feeling guilty. Industry versus inferiority is the developmental task of the school-age child, focusing on competence and self-esteem.

2. A 62-year-old female is being seen on a home visit by a nurse. The patient reports she has been taking Premarin for years. Which of the following would indicate an overdose?

Correct answer: A: Lower extremity edema

Rationale: Lower extremity edema can indicate an overdose of Premarin. Premarin, an estrogen hormone replacement therapy, can cause fluid retention leading to edema in the lower extremities. Sensory changes in the upper extremities, increased occurrence of fractures, and decreased peripheral blood flow are not typically associated with an overdose of Premarin.

3. The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery?

Correct answer: Contact lenses

Rationale: The correct answer is B: Contact lenses. It is crucial to remove contact lenses before surgery to prevent corneal drying, especially with non-extended wear lenses. Leaving the hearing aid or artificial eye in place does not pose harm to the client during surgery. While wedding rings are typically covered with tape, leaving them on is acceptable. Therefore, choices A, C, and D are incorrect in this scenario.

4. While performing wound care to a donor skin graft site, the nurse notes some scabbing at the edges and a black collection of blood. What is the nurse’s next action?

Correct answer: Gently remove the debris and re-dress the wound

Rationale: When the nurse notes scabbing at the edges and a black collection of blood, it indicates the presence of debris that needs to be addressed. Leaving the scabbed area alone and applying extra ointment may not address the underlying issue and could lead to complications. Notifying the physician is important in some cases, but immediate action is required to prevent infection in this situation. Gently removing the debris and re-dressing the wound is the correct course of action to promote healing and prevent complications.

5. The nurse is educating a teenage female about preventing the transmission of genital herpes. Which of the following statements should the nurse include?

Correct answer: “This infection can be transmitted via intercourse even when you do not feel ill.”

Rationale: Genital herpes can be transmitted through oral, genital, and anal sex. It is crucial to educate the patient that the infection can be transmitted via intercourse even when asymptomatic to prevent its spread. Choice A is incorrect as sitting on toilet seats without protection does not transmit genital herpes. Choice B is incorrect because oral sex can transmit the virus. Choice D is also incorrect as drinking fluids after sex does not prevent the transmission of genital herpes.

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