Bowtie: Physiological Adaptation – NCLEX-RN®

by Rhonda Lawes, PhD, RN

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    00:00 Hi. I'm Professor Lawes and today I'm going to walk you through the NCLEX format question known as BOWTIE.

    00:08 Now, this was going to come from the section called Physiological Adaptation.

    00:12 So stick with me thru this short video and we'll take a look at the best strategies you could use to get your highest score on these NCLEX questions.

    00:22 So we always start with a picture. You see here that the nurse is caring for a young adult client.

    00:28 So, obviously they're in like an ER-type setting.

    00:33 Now, when you're looking at your question, I'll show you in just a little bit what it will look like on this actual screen when you're taking your NCLEX test.

    00:41 Right now, I'm just going to walk you through the wording.

    00:44 So on the nurse's notes, we see med-surg history.

    00:47 He has an appendectomy at 16 years, no other diagnosis noted. Lungs are clear. +3 peripheral pulses palpated.

    00:55 Neurological assessment unremarkable. BMI 31. Smokes 3-4 packs a day of cigarettes.

    01:03 Alcohol consumption of 3-4 beers a day. Client reports a sedentary lifestyle.

    01:09 And client reports several home blood pressure readings greater than 140/90 mm/Hg.

    01:16 Alright, so we kind of get a background on this guy.

    01:19 Let's go through it one more time and look at what's normal, abnormal, or might put this patient at risk.

    01:25 So we know they had surgery at 16 years of age, no other diagnosis. So that's a pretty simple and straightforward surgical history.

    01:34 Lungs are clear. That's normal. +3 peripheral pulses. That's normal. So, not concerned there.

    01:41 Neurological assessment tells us it's normal, it's unremarkable.

    01:44 So we would know that that would mean the patient was awake, alert, and oriented. BMI of 31 is above normal.

    01:52 Smokes 3-4 packs a day. Wow! This is a risk factor. So, remember when you're talking with patients to be non-judgmental.

    02:01 Be kind, make eye contact, but just note that this could be a risk factor that could impact this patient.

    02:07 Alcohol consumption of 3-4 beers a day is more than recommended. Typically, that should be 1-2 beverages a day.

    02:17 Sedentary lifestyle doesn't help anybody out. Right? That kind of starting to put together a picture of risk factors.

    02:24 And finally, their blood pressure is... They've taken several readings at home that were greater than 140/90. So that is clearly hypertension. Right? It's too high.

    02:37 Next, let's talk about is vital signs. Temperature, that's normal. Right? 98.6 Fahrenheit, 37 degrees Celsius, right on the money.

    02:46 Heart rate, 90 is a little higher than you would expect, but it's still within normal range.

    02:52 On the NCLEX, 60-100 beats a minute is considered normal. Respiratory rate of 18. Uhhmm on the high end but still normal.

    03:02 146/98 for a blood pressure, that's too high. That would be considered hypertension.

    03:10 Next, let's talk about his lab work. There are several pieces of information there, but here is the great news.

    03:18 When they went to the new format for the next gen NCLEX, they decided they are going to include reference ranges for labs.

    03:25 People before the next gen had to have all these lab works memorized, but here you go.

    03:30 You'll see the result down the middle column and you've got the reference range on the right.

    03:35 So that is one thing you don't have to worry about when you're taking your NCLEX exam.

    03:39 So you have BUN and creatinine. What organ does that tell you about? Hematocrit. Total cholesterol.

    03:47 Work your way through each one of the lab values and note any that seem to be outside of the normal limits and what organ function they're giving us some information about.

    03:59 Now, what you see on the screen is what the actual NCLEX exam type question will look like.

    04:05 You see on the left side, those are all tabs. You see, nurse's notes, vital signs, laboratory values.

    04:12 When you're taking the NCLEX exam, you can click on any one of those tabs and read the information.

    04:17 You could go back as many times as you want, but I would encourage you to go through it slowly and thoroughly the first time so you don't have to do too much extra clicking.

    04:27 On the right side, that's what we're going to do the work of answering the question.

    04:31 Now look at what you see on the right hand side. This is where it gets its name, BOWTIE.

    04:38 2 on the left, 1 in the middle, 2 on the right, it has the shape of a bowtie and that's why we call it that.

    04:46 Then underneath there, you have those 3 columns. Right? So, the one column underneath the 2 boxes on the left, those are going to be the answer choices for those 2 boxes.

    04:57 In the middle directly beneath the middle portion, the middle box, those are the answer options for that box.

    05:04 And then on the far right, those are the answer options for the 2 boxes on the far right. Now you see the tabs as we move them.

    05:13 On this slide, you have the nurse's notes. Then we see if... let's click on the vital signs tab.

    05:19 You see the vital signs are there. Now let's click on the laboratory values tab.

    05:24 That's what it would look like to you. Now, you and I have already gone through all of these. Right? We've already looked at each one of these tabs. We just did it kind of in a blown-up version so it's easier for you to see.

    05:34 But this is the format that you'll find on your NCLEX exam. So let's take a look at where should we start.

    05:41 Well, I'm going to start on the left side. Look through all of those and kind of get a feel for what I'm looking for. It says actions to take.

    05:50 In the middle, I have potential condition. And on the right, what should I monitor? Now before I really take a look at these things, it's okay if you want to start in the middle. Yeah, it's fine, if you like to.

    06:06 So, did we see any results that would lead us towards diabetes type 2? Did you see results that indicated hypertension? Did you see results that indicated chronic kidney disease? What about metabolic syndrome? The easiest way to do this is to go back and look at the information. What you can't remember, double check and see how do these all lay out.

    06:34 Which one of these would be the most likely definition or condition that we would be treating? Now, when you look on the left in the Actions to Take column, you'll see that you have several options but they don't tell you which condition they go to.

    06:50 So, I really like to start on the left and look at each one of those interventions.

    06:57 Why would we do those? How would it help us? How it helped the patient stay safer? So notice I've given you 2 strategies.

    07:05 You can start in the middle if you feel pretty sure that's what the condition is.

    07:11 If you look at it, you back it up, you've eliminated the other categories you think "Nope, I'm going right for this one." It's perfectly fine for you to start in the middle and then go to the Actions to Take or Parameters to Monitor. That's perfectly acceptable.

    07:26 If you want to start on the left and work your way over, that's also an excellent strategy.

    07:31 So, let's start that because we're going to have to complete this diagram, here's the directions from the NCLEX exam.

    07:39 Complete the diagram by dragging from the choices below to specify which condition the client is most likely experiencing, 2 actions the nurse takes to address that condition, and 2 parameters the nurse monitors to assess the client's progress.

    07:53 Then let's take a look at the Actions to Take.

    07:55 Like I said, you could start in the middle if you wanted to but I'm going to start on the left hand side and work your way all the way through it.

    08:03 Now the first option says teach about the administration and side effects of metoprolol.

    08:10 Well, I didn't see any orders that ordered that. Did you? It's okay. Is this an appropriate choice for this patient? What do we remember about this patient? We looked at lab work. It assessed the kidneys. We looked at cholesterol. We looked at blood pressure.

    08:27 What thing stood out to you is being kind of at a line abnormal. Well, metoprolol is a/or metoprolol if you prefer to pronounce it that way.

    08:37 This medication is a beta-blocker used to treat blood pressure.

    08:41 Among several other uses including anxiety and other things, but for now looks like this could be a logical fit.

    08:48 We know the patient have high blood pressure and metoprolol would be an acceptable choice of medication.

    08:55 It's okay that we haven't seen an order for that, but we know that this would be an appropriate intervention.

    09:02 The next option we're looking at is increased water intake to 4 liters a day. That's a fair amount of water.

    09:09 Now you have to think about how would this help this patient? The abnormal lab work predominantly involved hypertension. Right? A high blood pressure.

    09:18 Would increasing the water intake to 4 liters a day help the high blood pressure? No, if anything if it did have an effect, it might raise the blood pressure by having more fluid on-board, but this doesn't seem like a better option than the metoprolol or metoprolol that will address the high blood pressure.

    09:38 Now we've got to instruct the client to exercise for 30 minutes 4 to 5 days a week. Well, exercise helps everyone.

    09:47 Now we're not talking about, you know, really pumping hard.

    09:50 We're really talking about activity being mobile particularly if you have a client that has been absolutely sedentary you want them to be able to sustain the program that they start.

    10:00 So being active for 30 minutes 4-5 days a week, would that address the problem? Well, if we think it's hypertension, yes.

    10:09 Even if we thought it was diabetes, yes. See, exercise helps everything. So, do I think that's a better idea than the water? Yup.

    10:18 So I'm going to leave it in and let's see what our other options are just in case that might be a better option.

    10:25 Instruct the client to consume a low potassium diet.

    10:31 Okay, that would be true if they have renal failure but what I'm really worried about since I know that their blood pressure is kind of elevated, that's why we're thinking the metoprolol and exercise might be a good idea.

    10:42 I would want them to eat a low sodium diet, not a low potassium diet.

    10:48 Low sodium because wherever sodium goes, water follows. So the client's ingesting a lot of sodium per day then they're going to hang on to extra fluid.

    10:58 So, this is not an option. This is not going to be the best action to take for this patient.

    11:05 Last one, perform glucose monitoring before meals. Whoah. Okay, I will go back and look at the lab values.

    11:12 Was there anything that indicated that this patient was diabetic? Look at their hemoglobin A1c. What was the result? Good.

    11:24 These glucose levels are a little higher than we would like them but the patient will be more of a pre-diabetic diagnosis versus diabetic diagnosis.

    11:32 So what we want them to do these things to kind of minimize the risk, lose some weight, be more active, all those types of positive healthstyle movements.

    11:41 It doesn't trump giving the blood pressure medication, right, and exercising multiple times a week.

    11:49 So, I'm not going to pick "perform glucose monitoring." So the 2 answers I pick, "teach the patient about the blood pressure medication they'll be taking" and encourage them or instruct them to exercise 4-5 times a week at 30 minutes each.

    12:06 Okay, so that's what I'm picking as my actions to take because I kind of had a suspicion that in the middle potential condition I'm thinking it was hypertension.

    12:17 But let's look at each of the answer choices, make sure we've eliminated them because we don't want to make a mistake.

    12:23 So even though I think it's hypertension, I'm going to do the work of working through all those answer choices.

    12:28 So first, diabetes type 2, we already said; hemoglobin A1c, not indicative of diabetes, probably pre-diabetic but it's not diabetes, it's not our main problem here with this patient.

    12:42 Hypertension, yeah, we're leaning toward that one.

    12:46 The BMI, the elevated cholesterol, the LDL, the high LDL, the low HDL increases our risk of cardiovascular events so we would want to treat the hypertension.

    12:57 So that's the one I think I'm going with but I'm still going to do the rest of the work.

    13:01 Chronic kidney disease. Okay, well hypertension can impact our kidneys, it can harm them.

    13:08 However, if you look at the lab values that teach your or show you how the kidneys are functioning, do they look fine or are they abnormal? They're fine. So, they wouldn't be chronic kidney disease because chronic kidney disease means it's established and it's going on for a long period of time. None of the lab work would indicate that.

    13:30 Alright, one more. Metabolic syndrome.

    13:34 Now remember that metabolic syndrome is looking at multiple factors that end up increasing the client's risk for hypertension, stroke, all kinds of cardiovascular events.

    13:45 So since this is a risk factor and the client does have some of these risk factors, we want to make sure that what we chose is a higher priority than metabolic syndrome.

    13:58 So, do we want to improve the symptoms that the patient has with metabolic syndrome? Yes, however, I can only put one answer in that middle box and it's a higher priority to treat the hypertension right now.

    14:14 So we've got hypertension. Move it up, you're going to click it and drag it up into the box just like you saw on the screen.

    14:21 Now we're left with what's most important for you to monitor.

    14:25 What's the focus of the question? Hypertension. Alright, so what's most important for you to monitor for a patient who has hypertension? Well, look at our options. We're going to pick 2 blood pressure. Well that one's kind of an easy one. Right? If someone has hypertension, we're trying to treat it with lifestyle changes and medication, monitoring the blood pressure makes perfect sense.

    14:48 So I'm thinking that one is probably going to stick around, but I'm going to do the work and look at the other answer choices.

    14:54 Urine output. No, that's not our top priority because the kidney function appears to be normal.

    15:00 So, looking at urine output is not a high priority. It's definitely not higher than blood pressure.

    15:07 BUN and creatinine, we already established that the patient's values are normal but we also know that high blood pressure can cause damage to kidneys.

    15:18 So, I'm going to leave it in there for now. Now, let's look at the last 2 remaining ones. Waist size.

    15:26 Well that is related to metabolic syndrome, but our focus is on hypertension.

    15:31 So, that does not trump the 2 choices we've already selected. And the last one is blood glucose.

    15:38 Now, we've already established for a patient with hypertension, that's not our highest priority and the patient didn't indicate that they had diabetes by their lab work.

    15:47 We just thought they might be likely pre-diabetic.

    15:51 So the 2 answers that we picked is the highest priority, blood pressure and BUN and creatinine because those monitor kidney function and we know that hypertension can cause damage to the kidneys. Again, don't argue with the screen.

    16:06 You may pick something else as being more important about somebody who has hypertension, but the NCLEX elves who write the question wants you to pick 2 from the 5 that they have given you there.

    16:17 So don't stress out about that or think that wouldn’t be your top 2 priorities.

    16:22 It's got to be from the choices that they provide. And that's it. You've finished a BOWTIE question.

    16:28 Remember, you can start on the left and work your way all the way through.

    16:32 You can start in the middle and then go back and do the left and right side.

    16:36 It's completely up to you, but when you're finished make sure you go through, read through each of those, and make sure that it makes sense.

    16:46 And you're done with the BOWTIE question.

    16:48 Now, good luck and keep practicing with the other examples we have available to you in our NCLEX review course.

    About the Lecture

    The lecture Bowtie: Physiological Adaptation – NCLEX-RN® by Rhonda Lawes, PhD, RN is from the course Next Gen NCLEX-RN® Question Walkthrough.

    Included Quiz Questions

    1. Blood pressure
    2. Blood glucose level
    3. Electrolyte levels
    4. Abdominal circumference
    5. HbA1c level
    1. Ask the client if they intend to attempt suicide.
    2. Place the client in a secluded area where they can rest.
    3. Notify the inpatient psychiatric unit of the client’s arrival.
    4. Offer the client lorazepam for anxiety.
    1. Sepsis
    2. Addisonian crisis
    3. Neuroleptic malignant syndrome
    4. Erysipelas

    Author of lecture Bowtie: Physiological Adaptation – NCLEX-RN®

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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