How to Answer Drop-Down Cloze Questions on the NCLEX Exam


Hello everyone, it's Nurse Sarah here! Today, I'm going to guide you through one of the more unique question types you might encounter on the Next Generation NCLEX (NGN) exam—the drop-down close question. This question type can be a bit tricky, so it's crucial to understand how to approach it effectively. Let's get started!

What is a Drop-Down Close Question?

A drop-down close question differs significantly from the traditional multiple-choice or select-all-that-apply questions. Instead of choosing from a list of predetermined answers, you're required to fill in the blanks within a given statement or scenario by selecting options from drop-down menus. This type of question is designed to test not only your knowledge but also your ability to apply that knowledge in a clinical context.

In a drop-down close question, you are presented with a scenario—often drawn from real-world nursing situations. The scenario will include patient information, such as clinical history, lab results, and vital signs, which you will need to analyze carefully. The question then asks you to complete a statement by selecting the correct options from the drop-down menus provided.

Understanding the Question Structure

Before diving into a sample question, it's important to understand the structure of these questions:

  1. Scenario Presentation: This part gives you the background information necessary to answer the question. It might include details about the patient’s current condition, medical history, lab results, and other relevant clinical data.

  2. Drop-Down Menus: You will find one or more blanks within a statement that you need to fill by selecting the appropriate option from a drop-down menu. Each menu offers several choices, and only one will be correct based on the scenario provided.

  3. Clinical Application: The primary goal is to assess your ability to interpret clinical data and apply your knowledge in a way that reflects real-life nursing responsibilities. This includes understanding medication administration, monitoring for adverse effects, and making critical decisions about patient care.

Example Question Breakdown

Let's walk through a detailed example to illustrate how to approach a drop-down close question effectively.

Scenario:

On the left side of your screen, you see that a nurse is providing care to a 36-year-old female patient who has been admitted for a new onset of seizures. The patient’s electronic health record (EHR) is accessible, and you can view various tabs such as health history, nurse's notes, vital signs, and lab results. For this question, the lab results tab is open.

The lab results show that at 7:45 AM, the patient had a phenytoin level test, with a result of 22 micrograms per milliliter. The normal therapeutic range for phenytoin is 10 to 20 micrograms per milliliter.

Question:

On the right side of the screen, the scenario continues with the following instructions:

"The nurse knows that this phenytoin level is _____, which means the blood level is _____. The nurse will monitor for _____, _____, and ____."

Now, let's break down the process of answering this question.

Step 1: Assess the Phenytoin Level

First, you need to evaluate the lab results provided. The patient’s phenytoin level is reported as 22 micrograms per milliliter. Given that the normal therapeutic range for phenytoin is between 10 to 20 micrograms per milliliter, it is clear that the patient’s level is above the normal range.

Action: Select “high” from the first drop-down menu to indicate that the phenytoin level is elevated.

Step 2: Determine the Blood Level Status

Next, you need to interpret what the high phenytoin level means for the patient’s clinical status. Since the level is above the therapeutic range, it indicates that the patient is experiencing phenytoin toxicity. Toxicity occurs when the drug concentration in the blood exceeds the safe range, potentially leading to adverse effects.

Action: Select “toxic” from the second drop-down menu to correctly identify the blood level status.

Step 3: Monitor for Signs of Toxicity

The final part of the question asks you to identify which clinical signs and symptoms you should monitor for in a patient with phenytoin toxicity. Understanding the pharmacology of phenytoin is key here.

Pharmacology Review of Phenytoin

Phenytoin is an anticonvulsant medication primarily used to manage seizure disorders, including tonic-clonic (grand mal) and focal (partial) seizures. It works by stabilizing neuronal membranes and decreasing the excitability of neurons that can lead to seizure activity.

Therapeutic Range: The effective therapeutic range for phenytoin is 10 to 20 micrograms per milliliter. Levels below 10 are considered subtherapeutic, meaning the patient may not receive enough medication to control seizures, putting them at risk for further seizure activity. Levels above 20 are considered toxic, increasing the risk of serious side effects.

Common Side Effects: Phenytoin can cause various side effects, even within the therapeutic range. These include gingival hyperplasia (enlarged gums), hirsutism (excessive hair growth), and folic acid deficiency. However, when levels exceed the therapeutic range, more severe toxic effects can occur.

Toxicity Signs: Phenytoin toxicity can manifest in several ways, with early signs including nausea, vomiting, and gastrointestinal discomfort. As toxicity progresses, neurological symptoms become more prominent, such as:

  • Lethargy: Patients may become excessively drowsy and less responsive.
  • Ataxia: This refers to a lack of muscle coordination, leading to unsteady movements and difficulty with tasks that require fine motor control.
  • Nystagmus: Involuntary, rapid eye movements can occur, which are often an early sign of phenytoin toxicity.

Less Common but Serious Toxic Effects: In severe cases, phenytoin toxicity can lead to confusion, stupor, or coma. It may also cause cardiovascular issues, such as hypotension and arrhythmias, especially when administered intravenously too quickly.

Answering the Monitoring Section

Given the above information, you would monitor the following in a patient with phenytoin toxicity:

  1. First Drop-Down Menu: Select “lethargy”. This symptom is a key indicator of neurotoxicity associated with high levels of phenytoin.

  2. Second Drop-Down Menu: Select “ataxia”. This condition, characterized by a lack of muscle coordination, directly correlates with the effects of phenytoin on the central nervous system.

  3. Third Drop-Down Menu: Select “nystagmus”. Rapid, involuntary eye movements are a classic sign of phenytoin toxicity and indicate that the drug is affecting the patient’s neurological function.

Step 4: Decide on the Nursing Intervention

After identifying the signs of toxicity, the question asks what action the nurse should take next. This decision is critical in preventing further harm to the patient.

Given that the phenytoin level is toxic, the best course of action would be to stop administering the medication until further evaluation. Continuing to give the patient more phenytoin could exacerbate the toxicity, potentially leading to severe neurological impairment or other life-threatening complications.

Action: Select “hold the next dose and notify the healthcare provider” from the final drop-down menu. This ensures that the provider is informed about the patient’s current condition and can make an informed decision about adjusting the medication dosage or prescribing an alternative treatment.

Conclusion

Navigating drop-down close questions on the NCLEX can be challenging, but with a systematic approach, you can master them. Start by thoroughly analyzing the scenario, then carefully consider each drop-down option based on your clinical knowledge. Remember, these questions are designed to simulate real-life nursing decisions, so always think about what you would do in an actual patient care situation.

To recap:

  • Assess the patient’s lab results: Identify if levels are within the normal range, subtherapeutic, or toxic.
  • Determine the clinical implications: Understand what the results mean for the patient’s condition.
  • Monitor for specific signs and symptoms: Be aware of what to watch for based on the drug’s pharmacology and potential toxic effects.
  • Implement appropriate nursing interventions: Make critical decisions that prioritize patient safety and ensure effective communication with the healthcare team.

I hope this detailed walkthrough helps you feel more confident when facing drop-down close questions on the NCLEX exam. If you want to explore more videos in this series, you can access them through the link provided in the description below. Keep studying, stay focused, and good luck on your exam!

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