Learning Objectives
By the end of this section, you will be able to:
- Interpret information given in NCLEX question types that promotes critical thinking and the use of clinical judgment in PMH nursing
- Examine an unfolding case study in mental health as an exemplar of the type of NCLEX questions
A nursing skill for success on NCLEX, and in practice, is the ability to divide a clinical picture into its elements. This skill is useful in all areas of nursing practice and enables nurses to understand the complexities of client care. This understanding not only leads to planning of person-centered nursing care, it also enhances nurses’ personal satisfaction in their work.
Interpret Information Given in NCLEX Question Types
This section offers guidelines to interpret information presented in NCLEX question types. Nurses use critical thinking to interpret data, which leads them to apply clinical judgment. NCLEX question formats seek to measure knowledge necessary for safe practice at the entry level of nursing. The exam offers partial credit for select questions.
Drag and Drop
These question types pertain to a client care scenario. Answers are chosen by identifying the steps in a procedure or components of a process, such as prioritizing the client’s room placement or staff assignment or filling in blanks in a description. Taking the licensure exam, the computer screen shows information on the right and left sides. Answers are moved to appropriate spaces by dragging or by highlighting and clicking arrow keys. All options may or may not be used.
Multiple Choice/Multiple Response
Multiple choice questions have traditionally required application of knowledge and analysis of data, demonstrated by selecting one correct answer for one question. Multiple choice test questions still make up most of NCLEX items, providing statements that are answered from a list of options.
NCLEX-RN seeks to present higher-order multiple choice questions. This means answers come not from the candidate’s memory but from learning and problem-solving ability. Test-takers are asked to interpret data and apply clinical reasoning to address client situations. Questions may have more than one answer.
Highlight—Text or Table
This question type requires highlighting or removing highlighting by use of the computer mouse or keyboard. A case study provides client care information wherein the candidate highlights the cues prompting a nurse to plan interventions (take action). Questions of this type call for clinical decision-making and may have as many as ten possible answers. Partial credit is given for these questions.
Bow Tie/Trend
The bow tie question is identified by the visual design it forms on the computer screen. A client care situation is presented with data and the test-taker is to discern whether it requires or does not require nursing intervention. The scenario may offer cues to a potential complication of the client’s condition if interventions are not taken.
On the computer screen, tabs are located at the top of an image containing client information, for example, vital signs, nurses’ notes, or other data from the medical record. These test items are created to test all aspects of the CJMM: recognizing and analyzing cues, formulating and prioritizing hypotheses, generating possible solutions, taking actions, and evaluating outcomes of care as effective or not effective.
A trend test item prompts the nurse to forecast future client needs over time. Trend questions may utilize computer screen images similar to the bow tie to test candidates’ ability to predict and prepare for what may be needed next.
Examining a Case Study with NCLEX Style Questions
In order to make clinical judgments and decisions, nurses are called to reflect on what is known (from formal education or from life experience) and apply this to clinical scenarios. Nurses can practice these skills using case studies. An unfolding case study is an example of a client care scenario where the situation changes. This seeks to replicate a real-life situation and to call upon decision-making skills of the nurse to respond as client needs present or change.
Generating an action based on gathered cues is likely a cognitive process nurses have previously utilized. Other types of decision-making nurses use include predetermining success or selecting different actions based on changes in the situation. In the case study presented here, the nurse, Jan, prepares for the therapeutic relationship with the client, Dylan, in the emergency department.
Unfolding Case Study: Therapeutic Relationship
Dylan, a young adult, is referred to the emergency department from an appointment at the local mental health clinic for elevated vital signs and change in condition. Dylan was transported by a family member who remains in the waiting room.
| Stages of the Therapeutic Relationship | Sample Nursing Actions | NCLEX Style Questions |
|---|---|---|
| Preorientation Phase | Nurse determines recipients of care: Dylan, a young adult; family member who remains in the waiting room | During the preorientation phase of the therapeutic relationship, the nurse will:
|
Before meeting with Dylan, the nurse, Jan, reviews accompanying information, which reveals the following:
Referred for BP 160/102. No significant medical history, no known allergies. Prescribed Risperidone orally 4 mg daily (which was taken today) and lorazepam orally as needed for anxiety 0.5 mg twice daily (not taken × 48 hours).
Diagnosed with schizophrenia four years ago, used several antipsychotics over this time but experienced side effects, now has good control of symptoms; recently unemployed and now socially withdrawn; has complied with clinic appointments and medication adherence. No substance misuse history or currently. Lives alone, eats poorly, fears taking the bus to the grocery store.
Jan recognizes cues from the history.
| Stage of the Therapeutic Relationship | Sample Nursing Actions | NCLEX Style Questions |
|---|---|---|
| Preorientation Phase | Nurse prepares self, collects secondary data: Clinically significant: BP, prescribed medications and dosages and last dose; diagnosis history and experience with psychotropic medications; change in social history | The nurse collects secondary data during medical record review consisting of:
|
Upon interview, Dylan does not return Jan’s greeting, avoids eye contact, answers questions slowly, and appears to struggle with concentration.
Jan explains care and says, “I’ll be working with you while you’re here in the emergency department. How can we help you today? I understand you came from your clinic appointment.”
Dylan states, “They sent me here because of my blood pressure,” and correctly identifies the environment as the “hospital ER.” His clothing is soaked with perspiration. Dylan flexes fingers, shakes hands, swallows repeatedly, and states, “My neck feels tight.”
Vital signs: oral temp 38°C, pulse 116 irregular, respirations 28 irregular, BP 156/104, repeat BP 148/96.
At this stage, Jan recognizes cues, analyzes cues (identifies problems), and prioritizes (identifies the priority problem).
| Stages of the Therapeutic Relationship | Sample Nursing Actions | NCLEX Style Questions |
|---|---|---|
| Orientation Phase | Explains care (sets termination phase, i.e., “I’ll be working with you while you’re here in the emergency department”), collects primary data | An important aspect of the orientation phase is:
|
|
Rank these assessment items in priority order:
|
Jan offers basic hygiene and dry clothes to Dylan who begins to cry and states, “My back hurts now, what is wrong with me?” Jan helps Dylan to reposition, then retakes the vital signs: oral temperature 40°C, pulse 120 irregular, respirations 24 irregular, BP 126/76.
At this stage, Jan generates solutions (What can be done? What goals can be set?) and takes action (What nursing interventions are indicated? What medical orders can be anticipated?).
| Stages of the Therapeutic Relationship | Sample Nursing Actions | NCLEX Style Questions |
|---|---|---|
| Working Phase | Comfort measures, build trust, assure as to safety, monitor condition | During the working phase, the client’s condition begins to change as evidenced by:
|
| Psychosocial stability and advanced medical care are goals Manage moderate anxiety, offer relaxation technique, coordinate care |
A medical order that can be anticipated is:
|
Collaborating prescriber orders IV fluids, ECG, CXR, lab work, UA with C&S. Dylan is cooperative with phlebotomy and other procedures, then becomes increasingly confused, unable to provide urine specimen, stating, “Where am I? I can’t really stay here, can I? How can I get out of here?”
At this stage, Jan generates solutions (How can the nurse use the therapeutic relationship? What is the goal?).
| Stages of the Therapeutic Relationship | Sample Nursing Actions | NCLEX Style Questions |
|---|---|---|
| Working Phase | Anxiety is severe | The nurse recognizes deterioration in client’s condition with:
|
| Manage severe anxiety, repeat directions, reality orientation, assure as to safety | The nurse decides to utilize the therapeutic relationship to manage rising anxiety by:
|
Laboratory results returned with the following:
- Abnormalities of hyponatremia (Normal range: 136–145 meq/L)
- Creatine kinase (CK) elevation (Normal range: 30–170 units/L)
- ECG shows supraventricular tachycardia (Normal range: heart rate 50–100; QRS interval 0.08–0.10 seconds)
- WBC WNL (Normal range: 4000–10,000/µL)
- CXR normal (Normal result: clear lungs, no abnormalities noted)
At this stage, Jan takes action: What nursing interventions are indicated?
| Stages of the Therapeutic Relationship | Sample Nursing Actions | NCLEX Style Questions |
|---|---|---|
| Working phase | Lab work and CXR may rule out infection as cause of fever, blood pressure labile, elevated CK indicates muscle damage, fever is priority Prepare for transfer, participate in family and client teaching |
Select the laboratory value indicative of worsening physical condition:
|
Prescriber calls for admission to ICU for cooling blanket, cardiac monitoring, and supportive care.
Prescriber and nurse collaborate in discussion with client and family regarding necessity for higher level of care for treatment of possible severe medication adverse reaction.
Dylan verbalizes understanding and Jan tells Dylan, “I’ll go upstairs with you,” and Dylan answers, “Thank you, nurse—thank you for helping me.”
At this stage, Jan evaluates outcomes: Are the nursing interventions effective for the goal? How is Dylan’s medical condition changing? How is Dylan’s psychosocial condition changing? What is the next nursing action?
| Stages of the Therapeutic Relationship | Sample Nursing Actions | NCLEX Style Questions |
|---|---|---|
| Working/Termination Phase | Medical condition worsening; psychosocial condition improving-anxiety reduced due to nursing interventions Nursing action: Transfer of care-accompany client to ICU, give bedside handoff report to receiving nurse |
Select the behaviors indicative of improving psychosocial condition:
|
Assessment and Analysis
In this scenario, assessment information consists of secondary data in the form of a printed report from the community clinic. During this preorientation phase, Jan recognizes the following cues from this data:
Clinically significant: BP, prescribed medications and dosages and last dose; diagnosis history and experience with psychotropic medications; change in social history
Jan analyzes this information and continues to the orientation phase of the therapeutic relationship. Jan collects primary assessment data by interacting with Dylan, observing Dylan’s behavior, and taking the vital signs. Jan analyzes the combined data as:
Client responses: oriented to reality, social aspects blunted; diaphoresis, muscle rigidity, fever, elevated vital signs, moderate anxiety
Priority: potential life-threatening medication reaction, symptom cluster for neuroleptic malignant syndrome
Planning and Implementation
During analysis, Jan forms hypotheses about what could be causing the presenting problems. Jan determines problems of fever, elevated vital signs, and moderate anxiety may be due to medication reaction. Jan identifies the priority problem and begins to plan additional care and collaboration by generating solutions, considering: What can be done? Jan sets goals of treatment and reassures the client.
Comfort measures, build trust, assure as to safety, monitor condition
Psychosocial stability and advanced medical care are goals
Jan implements the plan, moving into the working phase of the therapeutic relationship.
Jan is working within a shortened time frame due to the severity of the client’s condition, which has the potential to worsen. Regarding delegation, though a licensed practical nurse or nursing assistant could provide some of the basic care, Jan will not delegate any tasks. Dylan’s condition is unstable and requires continual assessment by the professional nurse. Jan factors all this data into the decision-making. Jan takes action to implement the plan, considering: What nursing interventions are indicated? What medical orders can be anticipated?
Manage moderate anxiety, offer relaxation technique, coordinate care
Evaluation (and Revision/Continuation of Care)
As Jan is coordinating care with the prescriber, Dylan’s psychosocial status changes. Dylan becomes unable to cooperate with the ordered laboratory specimen collection due to confusion and anxiety escalating from moderate to severe. Jan evaluates the goal of psychosocial stability as unmet. Jan recognizes these cues of a change in condition, which necessitate a change in nursing approach.
Jan revises the plan of care and implements these nursing interventions. They are effective for psychosocial stability, though medical condition is worsening.
Manage severe anxiety, repeat directions, reality orientation, assure as to safety
Diagnostic test results come back, and the prescriber arranges a transfer to a higher level of care for intensive treatment.
Medical condition worsening; psychosocial condition improving—anxiety reduced due to nursing interventions
Nursing action: Transfer of care—accompany client to ICU, give bedside handoff report to receiving nurse
Dylan is now receptive to interaction with Jan and the prescriber, as they explain the transfer procedure and rationale. Dylan’s family member is brought into the conversation. This is the termination phase of the therapeutic relationship, and nursing care has been effective for goals of psychosocial stability and advanced medical care.