Writing Next Generation NCLEX-Style Case Study Questions

By Susan Sportsman, PhD, RN, ANEF, FAAN

Recently, our blog featured tips for developing Next Generation NCLEX (NGN)-style questions, particularly the revision of test questions faculty already include on their examinations. Revising these questions provides a strategy to adapt current test items to reflect the NGN process, since these knowledge questions represent many questions on the NGN exam.

Now let’s turn our attention to writing NGN Case Study questions. Although only three case studies will be on the NGN examination, all test-takers must respond to the six questions embedded in these case studies, regardless of how many total questions they receive. Case Studies are complex and require some thinking to create. However, I think they are fun to write—the exercise is very much like writing (a truly short) short story! Here are some suggestions for getting started.

    1. Begin with the objective(s) that emphasize the content you want students to apply. Keep in mind that the point of case studies (and NGN questions in general) is to evaluate how well students can apply content to a specific clinical situation.
    2. Develop a clinical problem that students must address that represents the objective(s) in your course. Ideas for this this problem might come from:
      • Clinical situations highlighted in past tests (or in test banks to which you have access).
      • Your own clinical experiences-or those of your colleagues.
      • Content outlined in the NCLEX Test Design.
      • Case Studies you use for class discussion or assignments for students.
      • NCSBN’s Top Priority Knowledge Statements or Skills
    1. The introduction to the case study scenario should include:
      • Client demographics (age, gender, brief and relevant social history)
      • Client history
      • Relevant environmental factors, such as where the client lives (own home, LTC facility, etc.)
      • Normal/abnormal findings (e.g., Physical assessment findings, V/S, Lab values, psychological behaviors)
      • Time considerations for the nurse/client
      • Client/Nurse Interaction
    1. The six questions in the case study should focus on the application of one of the cognitive skills highlighted in the Clinical Judgment Measurement Model (CJMM). Silvestri (2020) identifies questions that test-writers (and test-takers) ask themselves to understand each of the six cognitive skills.
      • Recognize Cues: What matters most?
      • Analyze Cues: What could it mean?
      • Prioritize Hypothesis: Where do I go to start
      • Generate Solution: What can I do?
      • Take Action: What will I do?
      • Evaluate Outcomes: Did it help?

Remember that the case study should represent situations that are appropriate for the level of student you are testing.  Later in the curriculum the questions should represent clinical judgment that a novice nurse is expected to use in actual practice.

Starting the Process of Writing a Case Study

As you begin to write your own case studies, an example might be helpful in integrating the NGN components into an actual case study. The case study below was written for students in an early nursing clinical course, such as Fundamental in Nursing. In addition, the NGN Resources website also provides examples of case studies written at the level of a novice nurse.

Note: The templates we developed for this post can be found on our Resources page. Feel free to use them.


An 86 y/o female is 1-day post-op repair of a hip fracture. A previously active senior, she fell in her front yard, fracturing her L hip. She did not receive immediate assistance for several hours, until a neighbor, on returning to his home, noticed that she was lying in her yard, and called 911. The client’s daughter is with her mother and is the primary historian. Her daughter says that prior to the fall, her mother had been lucid and able to take care of her own needs.

#1. Recognize Cues (Drag and Drop)

Drag & Drop the 4 cues the RN observed the initial assessment which require following up.

#2. Analyze Cues (Select All that Apply-N)

The RN is concerned about the client’s confusion. Identify factors that may be causes for this confusion.
a. Hospital Environment  *
b. Early indication of Alzheimer’s Disease
c. Use of Morphine for control of Pain  *
d. Anesthesia  *
e. Reduction in O2
f. Limited Sleep

#3. Prioritize Hypothesis (CLOZE)

Complete the following sentence by choosing from the following lists of options:

The client is at highest risk for developing

as evidenced by

#4. Generate Solutions (Matrix)

Confusion continues to be a problem for the client on day three post-surgery.

Which of the possible interventions to the problem are indicated and which are contraindicated?

The RN notifies the surgeon of elevated TPR, drainage at surgical site, and pain and received orders.

#5. Take Action (Highlighting)

Upon receiving the following physician orders, highlight those which the nurse should implement right away.

#6. Evaluate Outcomes (Matrix)

The nurse has performed the interventions as ordered by the physician for the client. For each assessment finding, click to specify if the finding indicates that the client’s condition has improved, has not changed, or become worse.

Case study questions are an important part of the NGN emphasis on measuring test-takers’ clinical judgment competence. Hopefully, the example above will give you some ideas for developing your own case study questions. You may notice that these questions are not exactly formatted like those on the NGN website. Currently, most of us do not have the necessary software to completely mimic the NGN questions. But simple templates can come close. Please don’t let the differences in the format of these questions stop you from using case study questions in your testing and classroom teaching.  Remember, the point of the NGN testing process is to assess new graduates’ ability to use good clinical judgment in a variety of clinical situations.  Giving students the opportunity to practice clinical judgment is key to their success on NCLEX and in clinical practice.


Silvestri, L. (2020) Higher-Cognitive Level Test Question:  A Starting Point for Creating Next Generation NCLEX Test Questions. White Paper. Elsevier.



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