Critical Thinking

1
Critical Thinking

• Strategies for Test Taking

2

• 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.

3
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

4

• 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.

5

• 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.
• Lets talk about how to figure out what the
  question is really asking.

6
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.

7

• 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.

8

• 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.

9
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.

10
Read this Question

• A 54 year old man is being treated for Addisons
  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?

11

• 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.

12
Huh?

• Not sure what Addisons 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.

13

• If the patient is receiving cortisone, Addisons
  disease must be something that requires
  cortisone, a hormone from the adrenal glands.
• You notice that dosages are both increased and
  decreased.

14

• Step 3 Use these clues to find the answer to
  the REWORDED question,
• What is true about adjusting cortisone dosage?

15

• 1) Dosage is increased when the blood glucose
  level increases. Is this true about cortisone?
• No, this sounds like insulin. Eliminate.

16

• 2) Dosage is decreased when dietary intake is
  increased. Is this true about cortisone?
• No, cortisone requirements are not related to
  diet. Eliminate.

17

• 3) Dosage is decreased when infection stimulates
  endogenous steroid secretion. Endogenous means
  within the patient
• If the patient is receiving cortisone for
  Addisons disease, he must have adrenal
  insufficiency. Therefore, infection cant
  stimulate steroid secretion. Eliminate.

18

• 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.

19
Another Example

• Which of the following would most concern the
  nurse during a patients recovery from surgery?
• 1) Safety
• 2) Hemorrhage
• 3) Infection
• 4) Pain control

20

• Instructor The correct answer is (2).
• Student Why isnt infection the correct answer?
  It says right here pointing to the textbook
  that infection is a major complication after
  surgery.

21

• 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 cant count this answer wrong!

22

• 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 wont get the opportunity to argue about
  questions on your NCLEX licensure examination.

23

• The NCLEX test makers dont throw questions out
  because you dont 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.

24
Another Example

• The mother of a 10 year old boy with IDDM calls
  the physicians office to discuss the childs
  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

25

• 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.

26
Reworded Question

• What advice should the nurse give the mother
  about her diabetic child who is hyperglycemic in
  the morning?

27

• Step 1 Read the answer choices to establish a
  pattern. There is one assessment answer (2) and
  three implementation answers (1), (3), and (4).

28

• Step 2 Refer to the question to determine if
  you should be assessing or implementing.
• The childs 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.

29

• 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.

30

• 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.

31
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?

32

• 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.

33
Reworded Question

• What is a complication after a thyroidectomy?
• Strategy MOST concerned indicates a
  complication.

34

• The correct answer is (3) because carpal spasms
  indicate hypocalcemia (decreased calcium from
  parathyroid involvement).

35
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?

36

• 1) Hypoglycemia
• 2) Viral Illness
• 3) Ketoacidosis
• 4) Hyperglycemic hyperosmolar nonketotic coma

37
Reworded Question

• What do these symptoms indicate?
• (3) is the correct answer.

38
Another Example

• The nurse assesses a patient with a history of
  Addisons disease who has received steroid
  therapy for several years. The nurse could expect
  the patient to exhibit which of the following
  changes in appearance?

39

• 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.

40
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.

41

• (4) is the only response where all of the
  components are correct.

42
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

43

• 1) Check vital signs
• 2) check urine for glucose and ketones
• 3) give 6 oz of skim milk
• Call the physician

44
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 SS of
  hypoglycemia give fast acting sugar and protein
  recheck BG in 15 minutes.

45
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.

46

• 1) The patients urinary output has increased.
• 2) The patients blood pressure has increased.
• 3) The patient has lost weight.
• 4) The patients peripheral edema has decreased.

47
Reworded Question

• What shows a positive response to treatment for
  adrenal crisis?
• You must know the SS of adrenal crisis
  hypotension, cool pale skin, increased urinary
  output, dehydration.

48

• The correct answer is (2).
• Why?

49
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?

50

• 1) Cloudy dialysate drainage return.
• 2) Distended abdomen.
• 3) Shortness of breath.
• 4) Weight gain of 3 pounds in 2 days.

51
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.

52

• 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.

53
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 dont know the particular subject
  matter, you can still extract the correct answer.