The cognitive level of questions refers to the type of mental activity such as critical thinking, and clinical reasoning required to answer the question.
The cognitive levels used to write test items for the NCLEX-RN are derived from the original Bloom’s taxonomy and the Bloom’s revised taxonomy of the cognitive domain.4,5 (See Table 2.1.) The lowest level of the taxonomy is the knowledge (or remem- ber) level and involves the ability to remember or recall facts. The next level of the cognitive domain, comprehension (or understand) requires you to interpret, explain, or understand the knowledge.
The application (or apply) level involves using information that you remember and understand and can apply in new situations. Analysis (or analyze) requires recognizing and differentiating relation- ships between parts and using clinical reasoning and critical thinking skills. Synthesis (or synthe- size) refers to the ability to take several pieces of information or clinical data and use them to make a nursing care judgment or decision. The next level FIGURE 2.9
Sample Video Item
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Application Level Item
Application level items test your ability to apply knowledge to a specifi c scenario. These questions draw on your ability to know and understand nursing content, and to then apply this infor- mation to a specifi c scenario or situation. (See Figure 2.10.)
FIGURE 2.10
Sample Application Level Item
81.
The nurse is to administer Polycillin (ampicillin) 500 mg orally to a client with a ruptured appendix. The nurse checks the capsule in the client’s medication box which is located inside of the client’s room. The dosage of the medication is not labeled, but the nurse recognizes the color and shape of the capsule.The nurse should next:
■ 1. Administer the medication to maintain blood levels of the drug.
■ 2. Ask another registered nurse to verify that the capsule is ampicillin.
■ 3. Contact the pharmacy to bring a prop- erly labeled medication.
■ 4. Notify the unit manager to report the problem.
Strategies for Answering Application Level Questions
■ Read the question and consider what informa- tion you already know and how that informa- tion should be used to answer this particular question.
■ Consider how information you can recall should be applied to nursing care for the client that is described in the scenario for the question.
■ Apply known formulas (divided dose/drip rate calculation), frameworks (for example Maslow’s hierarchy, developmental stages, stages of moral development), and procedural steps (how to administer a particular medication) to answer the question posed in the new clinical situation (scenario).
■ Double check your answer by recognizing what information you are applying to answer the question.
of the cognitive domain is evaluation (or evaluate).
Here you must check data, critique information, or judge the outcome of nursing care. The fi nal level of the cognitive domain is creation (or create). At this level, you must be able to generate new approaches to nursing care or develop a unique nursing care plan based on available information.
Test items can be written to test at all levels of the cognitive domain, but questions that are writ- ten for the NCLEX-RN exam are generally written at application levels and above because nursing requires the ability to apply knowledge to clinical situations, analyze data, think critically, prioritize information, make clinical decisions for client care, evaluate outcomes of nursing interventions or health care treatments, and create care plans based on spe- cifi c client needs. This book presents questions at the application level and higher.
Clinical reasoning refers to the higher order men- tal activities and critical thinking skills used to solve a problem or make a decision. Nurses use clinical reasoning, critical thinking, critical synthesis, clini- cal decision making, and make clinical judgments to provide safe client care. Understanding the types of test items written at various levels of the cognitive domain and strategies to answer them is key ( ) to success on the licensing exam. Examples of ques- tions at higher levels of the cognitive domain are provided here to assist you in further understanding the types of questions used on the licensing exam and the strategies you can use to answer them. A summary of the cognitive levels, with examples of question stems and strategies for answering them, is given in Table 2.2.
TABLE 2.1
Levels of the Cognitive Domain
■ Knowledge/Remember: Recognizing, recalling
■ Comprehension/Understand: Interpreting, exempli- fying, classifying, summarizing, inferring, compar- ing, explaining
■ Application/Apply: Executing, implementing, using knowledge appropriately in new or different situations
■ Analysis/Analyze: Differentiating, organizing, attributing
■ Synthesis/Synthesize: Putting parts together to form a whole; using data from several sources to form a conclusion or make a decision
■ Evaluation/Evaluate: Checking, critiquing, judging against standards or protocols
■ Creation/Create: Generating, planning, producing
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TABLE 2.2 Keys to Answering Test Questions from Various Levels of the Cognitive Domain Cognitive LevelDescriptionsExamples of Question StemsStrategies for Answering Questions ApplicationTransfer knowledge from classroom to clinical practice.To assess the breath sounds for a client with heart failure, where should the nurse place the stethoscope?
Use knowledge and understanding of how to auscultate breath sounds to assess a particular client. Use a formula or guidelines to perform calculations.The client is to receive 1,000 ml of fl uids in 8 hours. The intravenous administration set delivers 15 drops per minute. The nurse should regulate the infusion to provide how many ml per minute?
Apply appropriate formula to calculate an intravenous fl uid drip rate. Apply knowledge and understanding to new situations.Which nursing intervention is appropriate for this client?Use knowledge and understanding about nursing interventions and apply to the client’s particular situation. The nurse should instruct the client about which of the following side effects that may occur when the client takes this drug? Select all that apply.
Apply knowledge and understanding about drug side effects to instruct a particular client The nurse is teaching a client to use a metered-dose inhaler. In which order should the nurse instruct the client about the steps to take to use the inhaler?
Use knowledge and understanding of correct order of a skill or procedure to teach a particular client. AnalysisOrganize clinical data into relevant parts in order to make a nursing diagnosis, form a conclusion, or make a clinical decision.
Based on the clinical assessment, the nurse should formulate which nursing diagnosis?Review the client’s signs and symptoms to determine an appropriate nursing diagnosis. Review all data to determine if suffi cient data are available to make a decision.
Which of the following (data) indicates the need for (nursing action)?Analyze data to determine which nursing action to take next. Analyze data to determine priorities.Which client should the nurse care for fi rst?Organize information about a group of clients and determine which client requires nursing care fi rst. Distinguish relevant from irrelevant data.Which (data) indicate the nurse should assess the client further?Analyze data and determine if additional data are needed. Determine what data are needed to plan or implement care.Based on these fi ndings, the nurse determines the client is in xxxx stage of development.Analyze data/fi ndings and determine appropriate stage (of development). Which client is at risk for xxx?Analyze data about a group of clients with risk factors and determine client’s risk.
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SynthesisAssemble information from several sources to determine the best course of action.
After reviewing (data from the client and the chart), the nurse should fi rst? Based on this information (about side effects of medication) and the client’s current health status the nurse should instruct the client to xxxx?
Use information from a variety of appropriate sources such as the client, client responses to medical and nursing interventions, laboratory data, diagnostic tests progress notes to determine appropirate nursing action. After assessing the client, the nurse reviews the physician orders. The nurse should do which of the following fi rst? After reviewing the client’s rhythm strip, pain medication record, and vital signs chart, the nurse should next? Which of the following indicates the nurse’sbest response to the child’s parent? EvaluationMake judgments about the effectiveness of nursing care.Which statement indicates the client has understood the nurse’s teaching?Determine if the client understands the instructions based on the criteria established in the teaching plan. Use standards of care to determine the extent to which the client has met them.
Which of the following indicate the intended therapeutic effect has occurred?Evaluate effectiveness of a nursing intervention, drug, or treatment based on the intended or expected outcome. Critique care given by others.The nurse is observing an unlicensed nursing personnel turn a client. Which of the following indicates the nurse should intervene?
Evaluate appropriateness of care given by others according to standards of care and knowledge of scope of practice. The nurse has administered nitroglycerin to a client with chest pain. In 30 seconds the client’s chest pain should be?
Judge effectiveness of outcome of a nursing action (administering a drug) based on expected therapeutic effect. CreationCreate or develop a unique or individualized plan, report, or protocol based on client needs.
Which should be included in a discharge plan for the client? Select all that apply.Develop a discharge plan. Which of the following nursing interventions best meet this client’s needs?Individualize a standardized care plan for a specifi c client. The nurse is planning care for 6 clients. The staffi ng for the team includes 1 registered nurse and 1 nursing assistant. Which of the following clients should be assigned to the nursing assistant? Select all that apply.
Create a care management plan for a group of clients and team of health care professionals. The nurse is gathering information for a “hand off” for transferring the client from one nursing unit to another. The nurse should include which of the following information in the report. Select all that apply.
Create a detailed report about the client’s health status.
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The focus here is on obtaining suffi cient information to make a clinical decision, rather than analyzing data already available. The information may come from the client/family or members of the health care team. In synthesis level items, you must determine accuracy and usefulness of information for the par- ticular situation, sort relevant data from irrelevant data, and use it to plan or give nursing care. (See Figure 2.12.)
FIGURE 2.12
Sample Synthesis Level Item
9.
The nurse is reviewing the laboratory report with the client’s lithium level taken that morning prior to administering the 5 p.m. dose of lithium. The lithium level is 1.8 mEq/L. The nurse should:■ 1. Administer the 5 p.m. dose of lithium.
■ 2. Hold the 5 p.m. dose of lithium.
■ 3. Give the client 8 oz (236 ml) of water with the lithium.
■ 4. Give the lithium after the client’s supper.
Strategies for Answering Synthesis Level Questions
■ Read the question to determine what information is necessary to provide safe client care.
■ Determine if you have suffi cient and accurate information.
■ Interpret all data obtained in context of the ques- tion and the client’s needs.
■ Make a clinical decision about the relevant nurs- ing action.
■ Double check your answer by being sure that the information you have directs you to the correct answer.
Evaluation Level Items
Evaluation level items ask you to make judgments about care, determine the effectiveness of nursing care, or evaluate the extent to which an intended outcome has been achieved. Evaluation level test items can also ask you to determine if the care given by others (client/family, health care Analysis Level Items
Questions at this level ask you to analyze data, clusters of symptoms, implementation plans, and then make nursing diagnoses and clinical decisions.
These questions can also ask about what additional information should be obtained to make a clinical decision, plan care, or make a nursing diagnosis.
(See Figure 2.11.)
FIGURE 2.11
Sample Analysis Level Item
14.
An 8-month-old infant is seen in the well-child clinic for a routine checkup. The nurse should expect the infant to be able to do which of the following? Select all that apply.■ 1. Say “mama” and “dada” with specifi c meaning.
■ 2. Feed self with a spoon.
■ 3. Play peek-a-boo.
■ 4. Walk independently.
■ 5. Stack two blocks.
■ 6. Transfer object from hand to hand.
Strategies for Answering Analysis Level Questions
■ Identify the data presented in the scenario that lead you to draw a conclusion or make a nursing diagnosis.
■ Identify how the parts are related and how the nurse should assemble them to make a complete care plan.
■ Determine if you have suffi cient information to make a decision.
■ Review data from all sources possible (client’s vital signs, client’s responses to medication and treatments, chart information, client assignment list, etc.)
■ Double check your answer by determining that you have understand all of the components of care and have made the correct nursing decision based on those components.
Synthesis Level Items
Synthesis level test items ask you to use several pieces of information to make a clinical decision.
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test items may ask you to develop a plan of care, a discharge plan, or an action plan to manage quality improvement. (See Figure 2.14.)
FIGURE 2.14
Sample Creation Level Item
4.
The nurse is conducting a community pre- sentation on the early detection of colon cancer.Which of the following should the nurse encour- age members of the audience to report to their health care providers? Select all that apply.
■ 1. Fatigue.
■ 2. Unexplained weight loss with adequate nutritional intake.
■ 3. Rectal bleeding.
■ 4. Bowel changes.
■ 5. Positive fecal occult blood testing.
Strategies for Answering Creation Level Test Questions
■ Read the question to determine what is to be developed or created.
■ Consider all of the elements necessary to have a complete plan of care, discharge plan, etc.
■ Understand what is and is not appropriate to include in the plan being created and rule out inappropriate aspects of care for the client or situation presented in the scenario.
■ Double check your answer by reviewing the appropriateness of each of the elements in the plan you have developed.