Mastering the Creation of Bow-Tie Questions: Enhancing Clinical Judgment

Dianne Harris, EdD, MSN, RN, CNE

As nursing education evolves to meet the demands of the Next Generation NCLEX (NGN), faculty face the challenge of preparing students for new question formats that measure clinical judgment. The Bow-Tie question has emerged as a powerful tool to bridge this gap.

Understanding Clinical Judgment on the NCLEX 

The NCSBN defines clinical judgment as "the skill of recognizing cues about a clinical situation, generating and weighing hypotheses, taking action, and evaluating outcomes, for the purpose of arriving at a satisfactory clinical outcome." It's the visible result of two invisible mental processes: critical thinking and decision making. 

The Clinical Judgment Measurement Model (NCJMM) breaks this complex skill into six distinct steps: 

• Recognize Cues 

• Analyze Cues 

• Prioritize Hypotheses 

• Generate Solutions 

• Take Actions 

• Evaluate Outcomes 

  
  

What Makes Bow-Tie Questions Unique? 

True to its name, the Bow-Tie question has a distinctive appearance that sets it apart on NCLEX items. This standalone question format addresses all six clinical judgment functions through three option columns.

Bow-Tie Question

The structure is elegant in its simplicity. Students select one potential condition from the middle column, then choose two

nursing actions from the left column followed by two parameters to monitor from the right column. With five total points possible and partial credit available, this format rewards depth of understanding while measuring clinical judgment on a continuum. 

The Three-Step Creation Process 

The secret to crafting effective Bow-Tie questions? Work backwards.

Step 1: Determine The Correct Options (Tokens)

Start by identifying a disease process, then narrow to a specific concept. For example, you might choose cirrhosis of the liver as your disease process and hepatic encephalopathy as your specific concept. 

Your potential condition answer is the specific concept. Then build outward by selecting two correct nursing actions and two parameters to monitor that directly relate to hepatic encephalopathy. 

Step 2: Establish Your Incorrect Tokens

You'll need three additional tokens for each column. The key is plausibility: these alternatives should represent possible conditions associated with your disease process and actions or parameters that could reasonably apply to one or more of these conditions. For cirrhosis, you might include portal hypertension, esophageal varices, or ascites as alternative potential conditions. Consider nursing actions and parameters to monitor that are plausible for other listed conditions.

Step 3: Write Your Scenario 

Finally, craft a clinical scenario that includes client information, the diagnosis, and data supporting your potential condition along with other pertinent information. Consider which chart tabs will best present your information: Nurses' Notes, Laboratory Results, Vital Signs, Medications, or other relevant documentation. 

The scenario content must support not only your correct answer but also make the alternative tokens appear plausible enough to require genuine clinical reasoning to eliminate. 

Understanding the Scoring 

Bow-Tie questions use a Zero-One partial credit scoring method, representing a significant shift from traditional all-or-nothing scoring. Students can earn 0 to 5 points across the five targets, with each correct selection adding to their score. This polytomous scoring approach allows ability to be measured on a continuum, providing more nuanced assessment of clinical judgment skills. 

Why It Matters 

Bow-Tie question creation is an important skill for educators that offers more than just NCLEX preparation. They challenge students to think like practicing nurses, connecting assessment data to potential complications, planning appropriate interventions, and identifying critical monitoring parameters. This integrated approach to clinical judgment prepares students not just to pass an exam, but to provide safe, effective client care. 

By incorporating Bow-Tie questions into your testing strategy, you're giving students the practice they need to succeed on the Next Generation NCLEX while simultaneously developing the clinical reasoning skills that will serve them throughout their nursing careers. 

For additional information, please visit: https://www.ncsbn.org/exams/exam-statistics-and-publications/exam-publications.page 

© SPIN-Learning

January 17, 2026