I just wrote a critical
thinking test item….or, at
least I think I did!?!
Linda Caputi, MSN, EdD, RN, CNE, ANEF
©2016, Linda Caputi, Inc; www.LindaCaputi.com
Let’s look at Cognitive
Domain and Critical
Thinking Test Items
©2016, Linda Caputi, Inc; www.LindaCaputi.com
Knowledge
(Remember) Level
• Remember previously learned information.
• Factual recall of information with no
judgments.
• Merely restate memorized facts.
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copyright 2016 Linda Caputi, Inc.
1
Knowledge Level
Test Item
The nurse is inserting a nasogastric tube into an
adult patient. In which position should the
patient be placed?
A. High Fowler’s
B. Left lateral
C. Prone
D. Trendeleburg
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Knowledge Level
Test Item
The nurse is inserting a nasogastric tube into an
adult patient. In which position should the
patient be placed?
A. Lying on the back
B. Lying on left side
C. Head low with feet elevated
D. Sitting with head elevated
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Comprehension
(Understand) Level
• Requires an understanding of the information
and ability to use it in a specific situation.
• Provide a rewording of memorized facts.
• Know what is being communicated without
necessarily relating to other material or
knowing full implications).
• Select or identify examples of the fact,
concept, principle, or procedure being
understood.
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copyright 2016 Linda Caputi, Inc.
2
Comprehension Level
Test Item
The nurse is evaluating a patient who is taking a
sulfa drug. Which statement by the patient
indicates the patient may be experiencing a
serious side effect of the drug?
A.
B.
C.
D.
“My leg muscles ache and I feel very weak.”
“I’ve been getting a lot of bruises lately.”
“I get dizzy when I get out of the chair.”
“I hear a ringing in my ears.”
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Application (Apply)
Level
• Apply concepts and theories as a basis for
responding to the item.
• Remember and apply general ideas, rules, and
theories.
• Interpret, demonstrate, or predict situations,
processes, phenomena, and/or procedures.
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Application Level
Test Item
A patient has undergone surgery for repair of a
ureter. The patient has both a nephrostomy tube
and an indwelling urinary catheter in place. On
the first postoperative day, the nurse notes the
nephrostomy tube is no longer draining urine.
What action will the nurse take?
a. Notify the physician immediately.
b. Do nothing since this is a normal occurrence in
the first 24 hours.
c. Clamp the nephrostomy tube to promote drainage
from the indwelling catheter.
d. Irrigate the nephrostomy tube with 40 cc sterile
saline.
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copyright 2016 Linda Caputi, Inc.
3
Analysis (Analyze)
Level
• Break down and analyze the information; uses two or
more concepts to answer; set priorities.
• Discriminate complex information.
• Categorize the structure or organization of ideas;
identify the relationship of these parts as a whole.
• Examine cause-and-effect relationships.
• Detect recurring themes.
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Analysis Level
Test Item
The nurse is caring for a patient with acute asthma.
The patient is receiving albuterol nebulizer
treatments every 6 hours and PRN. Which
assessment information requires further action by
the nurse?
A.Pulse oximetry of 94
B.Reports a weight gain of 3 pounds over the last
two months
C.Serum potassium of 3.1 mEq/L
D.States feels slightly shaky after the nebulizer
treatment
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Teaching to the Cognitive Domain
• Students must be engaged in thinking at
this cognitive domain
•Align teaching strategies with the
cognitive domain
•Engage in active, meaningful learning
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copyright 2016 Linda Caputi, Inc.
4
Matching Cognitive Level of an Item
with Course Objective
Knowledge Level Objective:
Identify the purpose of a medication
Sample Item Stem:
The nurse is working with a patient with
diabetes mellitus. What will the nurse tell the
patient is the purpose of insulin?
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Matching Cognitive Level of an Item
with Course Objective
Comprehension Level Objective:
Interpret information obtained from a patient.
Sample item stem:
The nurse is working with a patient with
diabetes mellitus. Which statement by the
patient indicates an understanding of the
purpose of insulin?
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Matching Cognitive Level of an Item
with Course Objective
Application Level Objective:
Use assessment data to make decisions about
patient care.
Sample item stem:
A patient who is in the transitional stage of
labor complains of nausea and rates pain 9/10.
The nurse interprets fetal decelerations on
the fetal monitor. What action will the nurse
take at this time?
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copyright 2016 Linda Caputi, Inc.
5
Matching Cognitive Level of an Item
with Course Objective
Analysis Level Objective:
Analyze complex data to determine the best action to
take for a patient.
Sample item stem:
The nurse assesses the fundus of a new mother who
delivered 24 hours ago. The nurse notes that the fundus
is at the level of the umbilicus and boggy. The patient
stated she just voided a large amount of urine and denies
pain with urination. The nurse notes a small amount of
lochia rubra. What is the priority action for the nurse to
take at this time?
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Guidelines for Writing Critical
Thinking Questions
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1. Include a Rationale
A rationale is not a page number from the
textbook.
Rationales help students discover the thinking
behind the question.
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6
2. Write at the
Application or Analysis Levels
• Reflect the clinical setting
• Use the nursing process
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2. Write at the
Application and Analysis Levels
• Encourage prioritization
• Avoid defining the problem by name
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Example
Rather than:
Which nursing intervention should be
implemented for a patient with a paralytic ileus?
Ask:
The nurse assesses a patient 2 days postabdominal surgery. The patient complains of
diffuse abdominal discomfort. The nurse
notes few bowel sounds, distention, and lack
of flatus. The nurse should implement which
intervention?
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Write at the
Application and Analysis
Levels
• Write items that require knowledge of:
 Interventions
 Treatments
 Effects of medications, etc, etc, etc.
Then applied to a nursing situation.
©2016, Linda Caputi, Inc; www.LindaCaputi.com
The nurse performed a bladder scan on a
patient for residual urine. The nurse
obtained 80 milliliters of urine. What action
will the nurse take?
A.
B.
C.
D.
Instruct the patient to drink a lot of fluids.
Notify the primary healthcare provider.
Chart the results; no further action needed.
Check the patient’s blood pressure.
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3. Require Multilogical Thinking
This can also be thought of as “sequential
reasoning”:
A process of deliberation that requires at
least two logical steps .
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8
The nurse is caring for a patient experiencing
acute urinary retention secondary to
enlargement of his prostate gland. Which
intervention will the nurse anticipate
implementing?
A. Ask the nursing assistant to help the patient
take a warm bath.
B. Administer bethanechol chloride
(Urecholine).
C. Have the patient stand upright and place his
hands in warm water.
D. Insert a urinary catheter.
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4. Require a high level of discrimination
What is:
• best
• most important
• should be done first
• has the highest priority
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Require a High Level of
Discrimination
Require the student to choose from plausible
alternatives.
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9
Changing the Cognitive Level
Changing a lower level thinking question to a
higher level.
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The Concept of Stress:
Knowledge Level
The nurse is caring for a 24-year-old patient admitted
for a herniorrhaphy. Which piece of assessment data
indicates the patient may be experiencing stress?
1. Lab results indicate a fasting blood glucose of 96.
2. Heart rate 110; blood pressure 130/85
3. Respiratory rate of 12
4. Quiet tone of voice
©2016, Linda Caputi, Inc.
The Concept of Stress:
Comprehension Level
The nurse is caring for a 24-year-old patient admitted
for a herniorrhaphy. Which statement by the patient
prompts the nurse to further investigate the presence
of stress?
1. My girlfriend will be here soon and would like to stay
late.
2. How many patients are on this unit?
3. How long will I be here after the surgery?
4. My friend had this same surgery and ended up in the
ICU.
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copyright 2016 Linda Caputi, Inc.
10
The Concept of Stress: Application
The nurse is caring for a 24-year-old patient admitted
for a herniorrhaphy. The patient’s vitals are: BP: 140/90,
P: 90, T: 98.4; R: 22. The patient tells the nurse this is
his first hospitalization and that his friend had this
surgery and ended up in the ICU. What is the nurse’s
first action?
1. Check the chart for the surgical consent.
2. Discuss postoperative care of the incision.
3. Assess the patient’s ability to walk to the bathroom
for a urine specimen.
4. Ask if he has specific concerns he would like to
address at this time.
©2016, Linda Caputi, Inc.
Increasing the Cognitive Level
The nurse is caring for a patient who with an
electrical injury of the lower extremities.
Which priority assessment data should be
obtained from this client?
Suggestion: It would be better to give the
information about the patient rather than
simply provide a medical diagnosis. How does
this patient present? What are the assessment
data?
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Increasing the Cognitive Level
The nurse is caring for a patient with end-stage kidney
disease (ESKD). Which food selection by the client
demonstrates understanding of a low-sodium, lowpotassium diet?
Suggestion: This is merely a knowledge level question.
The information about the patient in ESKD is not
needed to answer the question. The student only needs
to identify the food that matches that type of diet.
The "low-sodium, low-potassium" diet should not be
part of the question; the student needs to use the
information about what type of diet is required for the
patient situation provided, then go from there.
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copyright 2016 Linda Caputi, Inc.
11
Practice Question: How would
you raise the cognitive level?
Select the person at highest risk for contracting a
communicable disease.
A. A person possessing active immunity to the
disease.
B. A person exposed to a host who has totally
recovered from the disease.
C. A person with passive immunity to the disease.
D. A person exposed to a host before the onset of
clinical symptoms.
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Let’s Take a Look at Some
Questions
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The nurse has just received report for 4 patients.
Which patient will the nurse assess first?
A. A patient with a chest tube in place for 4 days with
10 milliliters drainage during the last 8 hour shift.
B. A patient scheduled for a respiratory therapy
treatment who needs a sterile sputum specimen
sent for testing
C. A patient who is now complaining of shortness of
breath 30 minutes after the nurse administered
albuterol sulfate (Combivent)
D. A patient with chronic emphysema with a pulse
oximetry reading of 92%
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copyright 2016 Linda Caputi, Inc.
12
The nurse is caring for a patient who has just
returned to the unit following repair of an aortic
aneurysm. Which lab value requires further
action by the nurse at this time?
A.
B.
C.
D.
Blood urea nitrogen 21 mg/dL
Hemoglobin 8.1 g/dL
Serum glucose 163 mg/dL
Total serum cholesterol 315 mg/dL
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Which nursing diagnosis has the highest priority
for a patient experiencing the manifestations of
Meniere's disease?
A.
B.
C.
D.
Anxiety
Ineffective coping
Risk for injury
Social isolation
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Using the Critical-Thinking Flowchart
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Using Pre-Written Stems
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A patient is admitted to the hospital with
bipolar disorder.
– When taking the history, the nurse could expect
this patient to describe which manifestations?
– When taking the history, which information
would be most significant?
– Which question will the nurse ask the patient
first?
– To determine a patient’s self-care ability, it is
most important for the nurse to ask the
(patient, family member) which question?
• Which findings would be indicative of a
nursing diagnosis of _______________?
• Or problem of_______
• (Describe a situation.) What is the most
likely cause of the patient’s risk to fall?
• {Describe several assessment findings, such
as lab values vital signs, and fluid intake,
etc.} Then ask: The nurse will notify the
physician/primary healthcare provider of
which finding?
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• What is the most important goal of care for a
patient who is receiving (a certain medication,
treatment, etc.)
• A patient is diagnosed with (hypertension,
diabetes, etc.) Which outcome would the nurse
consider the most important for this patient?
• {Describe a patient’s condition, symptoms,
assessment findings, etc.} Then ask: Which
nursing diagnosis will the nurse plan to address
first? Or, which problem stemming from these
findings would the nurse address first?
• A patient is 12 hours postoperative and
begins to have difficulty breathing. Which
action will the nurse take first?
• The nurse {describe a treatment or nursing
intervention} for a patient with {describe a
medical condition or physical finding}.
Which action is most important for the
nurse to implement?
• A patient is started on (give a medication,
diet, etc.) Which statement by the patient
indicates the patient needs additional
teaching?
• To evaluate a nursing assistant’s ability to
{describe a procedure}, what action will
the nurse request the nursing assistant to
perform?
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Using Pre-Written Stems
• Identify the cognitive level
• Use the stems to provide a ready access to
higher-level questions.
• You still must write the key and plausible
distracters.
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©2016, Linda Caputi, Inc; www.LindaCaputi.com
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©2016, Linda Caputi, Inc; www.LindaCaputi.com
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