Critical Thinking Strategies for Test Taking • NCLEX questions are not about recognizing facts. • You must be able to correctly identify what the question is asking. • Do not focus on background information that is not needed to answer the question. • The NCLEX focuses on thinking through a problem or situation. Critical Thinking For Nurses • • • • • Observation Deciding what is important Looking for pattern & relationships Identifying the problem Transferring knowledge from one situation to another • Discriminating between possible courses of action • Evaluation according to established criteria • There are some strategies that you MUST follow on EVERY NCLEX type test. • You must ALWAYS figure out what the question is asking. • You must ALWAYS eliminate answer choices. • Choosing the best answer often involves choosing the best of several answers that have correct information. • This may entail your correct analysis and interpretation of what the question is really asking. • Let’s talk about how to figure out what the question is really asking. Reword the Question • The first step to correctly answering NCLEX questions is to find out what each question is really asking. • Step 1 – Read each question carefully from the first word to the last word. Do not skim over the words or read them too quickly. • Step 2 – Look for hints in the wording of the question stem. The adjectives most, first, best and initial indicate that you must establish priorities. • The phrase further teaching is necessary indicates that the answer will contain incorrect information. • Step 3 – Reword the question stem in your own words so that it can be answered with a “yes” or “no”, or with a specific bit of information. • Step 4 – If you cannot complete step 3, read the answer choices for clues. What if you are “clueless”? • No matter how well you prepare for an NCLEX type test, there may be topics you see on your test with which you are unfamiliar. • Reading the answer choices for clues will increase your chances of selecting a correct answer. • You just have to calm down to access this knowledge. Read this Question • A 54 year old man is being treated for Addison’s disease. The physician orders cortisone 25mg po daily. The nurse should explain to the patient that adjustment of the dosage may be required for which of the following situations? • 1) Dosage is increased when blood glucose level increases. • 2) Dosage is decreased when dietary intake is increased. • 3) Dosage is decreased when infection stimulates endogenous steroid secretion. • 4) Dosage is increased relative to an increase in the level of stress. Huh? • Not sure what Addison’s disease is? • Not sure how to adjust the dose of cortisone? • Step 1 – Read the question once. Resist the impulse to reread the question. • Step 2 – Read the answer choices. What should you be thinking? The question concerns cortisone. • If the patient is receiving cortisone, Addison’s disease must be something that requires cortisone, a hormone from the adrenal glands. • You notice that dosages are both increased and decreased. • Step 3 – Use these clues to find the answer to the REWORDED question, • “What is true about adjusting cortisone dosage?” • 1) Dosage is increased when the blood glucose level increases. Is this true about cortisone? • No, this sounds like insulin. Eliminate. • 2) Dosage is decreased when dietary intake is increased. Is this true about cortisone? • No, cortisone requirements are not related to diet. Eliminate. • 3) Dosage is decreased when infection stimulates endogenous steroid secretion. “Endogenous” means “within the patient” If the patient is receiving cortisone for Addison’s disease, he must have adrenal insufficiency. Therefore, infection can’t stimulate steroid secretion. Eliminate. • 4) The last answer is the correct one since it is the only one remaining. Even if you are not confident that cortisone is increased during periods of stress, you can conclude that this is the correct answer because the other choices have been eliminated. Another Example… • Which of the following would most concern the nurse during a patient’s recovery from surgery? • 1) Safety • 2) Hemorrhage • 3) Infection • 4) Pain control • Instructor: “The correct answer is (2).” • Student: “Why isn’t infection the correct answer? It says right here [pointing to the textbook] that infection is a major complication after surgery.” • Instructor: “Yes, infection is an important concern after surgery. But, if the patient has a life threatening hemorrhage, then the fact that the wound is infected is immaterial.” • Student: “But it says here on page 106 that infection is a major complication after surgery! You can’t count this answer wrong!” • In some situations, the faculty member will give you partial credit for your answer or will “throw the question out” because there is more than one right answer. • You won’t get the opportunity to argue about questions on your NCLEX licensure examination. • The NCLEX test makers don’t throw questions out because you don’t like them. • You either select the answer they are looking for or you get the question wrong. • In the previous question, all of the answers listed are important in caring for a postoperative patient, but only one answer is the best. Another Example • The mother of a 10 year old boy with IDDM calls the physician’s office to discuss the child’s self monitoring blood glucose home reading. • He is being tightly regulated with a combination of NPH and regular insulin before breakfast and supper. The past two mornings his BG readings were 220 mg/dL and 210 mg/dL. The nurse should advise the mother to: • 1) Continue with his medication regimen. • 2) Check his blood sugar during the night. • 3) Give his NPH insulin later in the evening. • 4) serve his bedtime snack earlier in the evening. Reworded Question… • “What advice should the nurse give the mother about her diabetic child who is hyperglycemic in the morning?” • Step 1 – Read the answer choices to establish a pattern. There is one assessment answer (2) and three implementation answers (1), (3), and (4). • Step 2 – Refer to the question to determine if you should be assessing or implementing. • The child’s mother tells you that the blood sugars have been elevated the last two mornings. This indicates there is a problem. • According to the nursing process, you should assess first. Eliminate options 1,3, and 4. • The correct answer is (2). • This question is about the Somogyi effect, which is rebound hyperglycemia that occurs in response to a rapid decrease in the blood sugar at night. • Treatment includes adjusting the evening diet, changing the insulin dose, and altering the amount of exercise to prevent nocturnal hypoglycemia. • Even if you have never heard of the Somogyi effect, you are still able to correctly answer this question using the assessment vs Implementation strategy. Another Example… • The nurse is caring for a 45 year old client who had a thyroidectomy 12 hours ago for the treatment of Graves Disease. The nurse would be MOST concerned if which of the following were observed? • 1) BP 138/82, pulse 84, respirations 16, oral temp 99F • 2) The patient supports his head and neck when turning his head to the right. • 3) The client spontaneously flexes his wrist when the BP is obtained. • 4) The client is drowsy and complains of a sore throat. Reworded Question • What is a complication after a thyroidectomy? • Strategy: “MOST concerned” indicates a complication. • The correct answer is (3) because carpal spasms indicate hypocalcemia (decreased calcium from parathyroid involvement). Another Example…… • A 26 year old man comes to the emergency room with complaints of nausea, vomiting, and abdominal pain. He is a type 1 diabetic. Four days earlier, he reduced his insulin dose when flu symptoms prevented him from eating. The RN performs a pt assessment which reveals poor skin turgor, dry mucous membranes, and fruity breath odor. The nurse should be alert for which of the following problems? • • • • 1) Hypoglycemia 2) Viral Illness 3) Ketoacidosis 4) Hyperglycemic hyperosmolar nonketotic coma Reworded Question • What do these symptoms indicate? • (3) is the correct answer. Another Example… • The nurse assesses a patient with a history of Addison’s disease who has received steroid therapy for several years. The nurse could expect the patient to exhibit which of the following changes in appearance? • 1) Buffalo hump, girdle obesity, gaunt facial appearance. • 2) Tanning of the skin, discoloration of the mucous membranes, alopecia, wt loss. • 3) Emaciation, nervousness, breast engorgement, hirsutism. • 4) Truncal obesity, purple striations of the skin, moon face. Reworded Question • What changes are seen in a patient after taking steroids on a long term basis? • Strategy: All of the options in an answer choice must be correct for the option to be right. • (4) is the only response where all of the components are correct. Another Example… • A patient receives 10 units of NPH insulin every morning at 8am. At 4pm the nurse observes that the patient is diaphoretic and slightly confused. The FIRST action the nurse should take is to: • • • • 1) Check vital signs 2) check urine for glucose and ketones 3) give 6 oz of skim milk Call the physician Reworded Question • What is the cause of these symptoms and what is the FIRST thing you should do? • The correct answer is (3): These are S&S of hypoglycemia – give fast acting sugar and protein & recheck BG in 15 minutes. And Finally…… • The nurse evaluates the care provided to a 42 year old man hospitalized for treatment of adrenal crisis. Which of the following changes would indicate to the nurse that the patient is responding favorably to medical and nursing treatment. • 1) The patient’s urinary output has increased. • 2) The patient’s blood pressure has increased. • 3) The patient has lost weight. • 4) The patient’s peripheral edema has decreased. Reworded Question • What shows a positive response to treatment for adrenal crisis? • You must know the S&S of adrenal crisis: hypotension, cool pale skin, increased urinary output, dehydration. • The correct answer is (2). • Why? One more…….. • After teaching the mother of a young child with a peritoneal catheter about the signs & symptoms of peritonitis, the nurse determines that the mother has understood the teaching when she identifies which of the following as an important sign? • • • • 1) Cloudy dialysate drainage return. 2) Distended abdomen. 3) Shortness of breath. 4) Weight gain of 3 pounds in 2 days. Reworded Question • Peritonitis is an INFECTION of the peritoneal cavity. Which symptom is consistent with an infectious process? • Abdominal distention, weight gain, and shortness of breath are associated with fluid excess – not infection. • The correct answer is (1). • Normally, dialysate drainage return should be clear. With peritonitis, large numbers of bacteria, white blood cells, and fibrin cause the dialysate to appear cloudy. What Did We Learn Today? • Answer what the question is asking. • All answers may sound good but you are going to have to select THE BEST ONE. • Even if you don’t know the particular subject matter, you can still extract the correct answer.