Multiple Choices and Multiple Responses
Let focuses on two other kinds of selected-response items: multiple-choice and multiple-response. Multiple-choice items, which have one correct answer, are used widely in nursing and in other fields. This test-item format includes an incomplete statement or question, followed by a list of options that complete the statement or answer the question.
Multiple-response items are designed similarly, although more than one answer may be correct. Both of these test-item formats may be used for assessing learning at the recall, comprehension, application, and analysis levels, making them adaptable for a wide range of content and learning outcomes.
Multiple-Choice Items and Learning Outcomes
Multiple-choice items can be used for measuring many types of learning outcomes. Some of these include:
■ Knowledge of facts, specific information, and principles
■ Definitions of terms
■ Understanding of content
■ Application of concepts, principles, and theories in clinical and other situations
■ Analysis of data and clinical situations
■ Comparison and selection of varied interventions
■ Judgments and decisions about actions to take in clinical and other situations.
Multiple-choice items are particularly useful in nursing to measure application- and analysis-level outcomes. With multiple-choice items, the teacher can introduce new information requiring application of concepts and theories or analytical thinking to answer the questions. Items at this level are effective for assessing critical thinking (McDonald, 2007).
Experience with multiple-choice testing provides essential practice for students who will later encounter this type of item on licensing, certification, and other commercially prepared examinations. Multiple choice items also allow the teacher to sample the course content more easily than with items such as essay questions, which require more time for responding. In addition, multiple-choice tests can be electronically scored and analyzed.
Disadvantages of Multiple Choice Questions
Although there are many advantages to multiple-choice testing, there are also certain disadvantages. First, these items are difficult to construct, particularly at the higher cognitive levels. Developing items to test memorization of facts is much easier than designing ones to measure use of knowledge in a new situation and skill in analysis.
As such, many multiple-choice items are written at the lower cognitive levels, focusing only on recall and comprehension. Second, teachers often experience difficulty developing plausible distractors. These distractors—also spelled distracters—are the incorrect alternatives that seem plausible for test-takers who have not adequately learned the content. If a distractor is not plausible, it provides an unintended clue to the test-taker that it is not the correct response.
Third, it is often difficult to identify only one correct answer. For these reasons, multiple choice items are time-consuming to construct. Some critics of multiple-choice testing suggest that essay and similar types of questions to which students develop a response provide a truer measure of learning than items in which students choose from available options.
However, multiple-choice items written at the application and analysis levels require use of concepts and theories and analytical thinking to make a selection from the available options. For items at those levels, test-takers need to compare options and make a judgment about the correct or best response.
How to Write Multiple-Choice Items and Its Parts
There are three parts to a multiple-choice item, each with its own set of principles for development:
(a) stem
(b) answer
(c) distractors
The stem is the lead-in phrase in the form of a question or an incomplete statement that relies on the alternatives for completion. Following the stem is a list of alternatives or options for the learner to consider and choose from. These alternatives are of two types: the answer, which is the correct or best response to answer the question or complete the statement, and distractors, which are the incorrect alternatives.
The purpose of the distractors, as the word implies, is to distract students who are unsure of the correct answer. Suggestions for writing each of these parts are considered separately because they have different principles for construction.
Stem
The stem is the question or incomplete statement to which the alternatives relate. Whether the stem is written in question form or as an incomplete statement, the most important quality is its clarity. The test taker should be able to read the stem and know what to look for in the alternatives without having to read through them. Thus, the stem should stand alone (McDonald, 2007).
One other important consideration in writing the stem is to ensure that it presents a problem or situation that relates to the learning outcome being evaluated. Guidelines for writing the stem are:
The stem should present clearly and explicitly the problem to be solved. The student should not have to read the alternatives to understand the question or the intent of the incomplete statement. The stem should provide sufficient information for answering the question or completing the statement.
An example of this principle follows:
Cataracts:
a. it is painful.
b. may accompany coronary artery disease.
c. occur with aging. d. result in tunnel vision.
The stem of this question does not clearly present the problem associated with cataracts that the alternatives address. As such, it does not guide the learner in reviewing the alternatives. In addition, the options are dissimilar, which is possible because of the lack of clarity in the stem; alternatives should be similar.
One possible revision of this stem is:
The causes of cataracts include:
a. aging
b. arteriosclerosis
c. hemorrhage.
d. iritis.
After writing the item, the teacher can cover the alternatives and read the stem alone. Does it explain the problem and direct the learner to the alternatives? Is it complete? Could it stand alone as a short answer item? In writing the stem, always include the nature of the response, such as, “What of the following interventions, signs and symptoms, treatments, data,” and so forth. A stem that simply asks “Which of the following?” does not provide clear instructions as to what to look for in the options.
Although the stem should be clear and explicit, it should not contain extraneous information unless the item is developed for the purpose of identifying significant versus insignificant data. Otherwise, the stem should be brief, including only necessary information. Long stems that include irrelevant information take additional time for reading.
This point can be illustrated as follows, using the previous cataract item: You are caring for an elderly man who lives alone but has frequent visits from his daughter. He has congestive heart failure and some shortness of breath. Your patient was told recently that he has cataracts.
The causes of cataracts include:
a. aging
b. arteriosclerosis.
c. hemorrhage.
d. iritis.
In this stem, the background information about the patient is irrelevant to the problem addressed. If subsequent items were to be written about the patient’s other problems, related nursing interventions, the home setting, and so forth, then this background information might be presented as a scenario in a context-dependent item set.
Stems should also not be humorous; laughing during the test can distract students who are concentrating . If one of the distractors is humorous, it will be recognized as implausible and eliminated as an option, increasing the chance of guessing the correct answer from among the remaining alternatives. Humorous content may be confusing to test takers for whom English is a second language.
Avoid inserting information in the stem for instructional purposes. In the example that follows, the definition of cataract has no relevance to the content tested, that is, the causes of cataracts? The goal of testing is to evaluate outcomes of learning, not to teach new information, as in this example:
Cataracts are opacity of the lens or capsule of the eye leading to blurred and eventual loss of vision. The causes of cataracts include:
- aging.
- arteriosclerosis.
- hemorrhage.
- iritis.
If words need to be repeated in each alternative to complete the statement, shift them to the stem. This is illustrated as follows: An early and common sign of pregnancy:
- is amenorrhea.
- is morning sickness.
- is spotting.
- is tenderness of the breasts.
The word “is” may be moved to the stem: An early and common sign of pregnancy is:
- amenorrhea.
- morning sickness.
- spotting.
- tenderness of the breasts.
Similarly, a word or phrase repeated in each alternative does not test students’ knowledge of it and should be included in the stem. An example follows: Clinical manifestations of Parkinson’s disease include:
- decreased perspiration, tremors at rest, and muscle rigidity.
- increased salivation, muscle rigidity, and diplopia.
- muscle rigidity, decreased salivation, and nystagmus.
- tremors during activity, muscle rigidity, and increased perspiration.
This item does not test knowledge of muscle rigidity occurring with Parkinson’s disease because it is included with each alternative. The stem could be revised as follows:
Clinical manifestations of Parkinson’s disease include muscle rigidity and which of the following signs and symptoms?
- Decreased salivation and nystagmus
- Increased salivation and diplopia
- Tremors at rest and decreased perspiration
- Tremors during activity and increased perspiration
Do not include key words in the stem that would clue the student to the correct answer. This point may be demonstrated in the earlier question on cataracts. You are caring for an elderly patient who was recently told that he has cataracts. The causes of cataracts include:
- aging.
- arteriosclerosis.
- hemorrhage.
- iritis.
In this item, informing the student that the patient is elderly provides a clue to the correct response.
Avoid the use of negatively stated stems, including words such as “no,” “not,” and “except.” Negatively stated stems are sometimes unclear; In addition, they require a change in thought pattern from selections that represent correct and best responses to ones reflecting incorrect and least likely responses. Most stems may be stated positively, asking for the correct or best response rather than the exception. If there is no acceptable alternative to a negatively stated stem, consider rewriting the item in a different format, such as true–false or completion.
Alternative
The stem and alternatives that follow should be grammatically consistent. If the stem is an incomplete statement, each option should complete it grammatically; if not, clues may be provided as to the correct or incorrect responses. It is also important to check carefully that a consistent verb form is used with the alternatives.
An example follows: Your patient is undergoing a right carotid endarterectomy. Prior to surgery, which information would be most important to collect as a baseline for the early recovery period? Her ability to:
a. follow movements with her eyes
b. move all four extremities
c. rotating his head from side to side
d. swallow and gag
Option “c” provides a grammatical clue by not completing the statement “Her ability to.” The item may be reviewed easily: Your patient is undergoing a right carotid endarterectomy.
Prior to surgery, which information would be most important to collect as a baseline for the early recovery period? Her ability to:
a. follow movements with her eyes
b. move all four extremities
c. rotate her head from side to side
d. swallow and gag
Avoid ending stems with “a” or “an” because these often provide grammatical clues as to the option to select. It is usually easy to rephrase the stem to eliminate the “a” or “an.” For instance, Narrowing of the aortic valve in children occurs with an: a. aortic stenosis.* b. atrial septal defect. c. coarctation of the aorta. d. patent ductus arteriosus.
Ending this stem with “an” eliminates alternatives “c” and “d” because of obvious lack of grammatical agreement. The stem could be rewritten by deleting the “an”: Narrowing of the aortic valve in children occurs with: a. aortic stenosis.* b. atrial septal defect. c. coarctation of the aorta. d. patent ductus arteriosus. Ending the stem with “a or an” or “a/an” is not a satisfactory alternative because these formats require test-takers to re-read each alternative with “a” first and then “an,” thereby increasing reading time unnecessarily.
If the stem is a statement completed by the alternatives, begin each alternative with a lower-case letter and place a period after it because it forms a sentence with the stem. At the end of the stem, use a comma or colon as appropriate. Use uppercase letters to begin alternatives that do not form a sentence with the stem. If the stem is a question, place a question mark at the end of the stem.
Each multiple-choice item should be independent of the others. The answer to one item should not be dependent on a correct response to another item, and the test-taker should not have to read another item to correctly interpret the item at hand. In the following example, the meaning of the second-item stem cannot be understood without referring to the stem of the first item:
You are the community health nurse developing a teaching plan for a 45-year-old man who was treated in the ER for an asthma attack. Which action should be implemented FIRST? to.
a. Assess other related health problems
b. Determine your level of understanding of asthma
c. Review with him treatments for his asthma
d. Teach him actions of his medications
On your second home visit, the patient is short of breath. Which of these statements indicates a need for further instruction? to.
a. “I checked my peak flow since I’m not feeling good.”
b. “I have been turning on the air conditioner at times like this.”
c. “I tried my Advair because my chest was feeling heavy.”*
d. “I used my nebulizer mist treatment for my wheezing.”
A better format would be to develop a series of multiple-choice items that relate to a patient scenario, clinical situation, or common data set (context-dependent item set), with directions that indicate the items that pertain to the given context.
Write the stem so that the alternatives are placed at the end of the incomplete statement. An incomplete statement with a blank in the middle, which the options then complete, interrupts the reading and may be confusing for students to read and follow ( Nitko & Brookhart, 2007). For example: The nurse should check for a patient receiving warfarin. to. activated clotting time b. complete blood cell count c. partial thromboplastic time d. prothrombin time
This item would be easier to read for students if the alternatives were placed at the end of the statement: For a patient receiving warfarin, the nurse should check the:
- activated clotting time.
- complete blood cell count.
- partial thromboplastin time.
- prothrombin time.
Alternatives
Following the stem in a multiple-choice item is a list of alternatives or options, which include
(a) the correct or best answer
(b) distractors
There are varying recommendations as to the number of alternatives to include, ranging from 3 to 5. The more options—as long as they are plausible—the more discriminating the item. Five options reduce the chance of guessing the correct answer to 1 in 5 (Miller, Linn, & Gronlund, 2009).
Unfortunately, it is usually difficult to develop four plausible distractors to accompany the correct answer when five options are included. For this reason, four options are typically used, allowing for one correct or best answer and three plausible distractors. Many standardized tests use four alternatives. General principles for writing the alternatives follow:
The alternatives should be similar in length, detail, and complexity. It is important to check the number of words included in each option for consistency in length. Frequently the correct answer is the longest because the teacher attempts to write it clearly and specifically.
Nitko and Brookhart (2007) suggested that the test wise student may realize that the longest response is the correct answer without having the requisite knowledge to make this choice. In that case, the teacher should either shorten the correct response or add similar qualifiers to the distractors so that they are similar in length as well as in detail and complexity.
Although there is no established number of words by which the alternatives may differ from each other without providing clues, one strategy is to count the words in each option and attempt to vary them by no more than a few words. This will ensure that the options are consistent in length. In the sample item, the correct answer is longer than the distractors, which might provide a clue for selecting it.
You are assessing a 14-year-old girl who appears emaciated. Her mother describes the following changes: resistance to eating and 20-lb. weight loss over the last 6 weeks. It is most likely that the patient resists eating for which of the following reasons? to. Complaints of recurring nausea. b. You describe yourself as “fat all over” and fearful of gaining weight.* c. Have other GI problems. d. Seeks her mother’s attention. The correct answer can be shortened to: Is fearful of gaining weight.
In addition to consistency in length, detail, and complexity, the options should have the same number of parts. The answer in the previous question is not only longer than the other options but also includes two parts, providing another clue. In the example that follows, including two causes in option “a” provides a clue to the answer. Revising that option to only “aging” avoids this. Causes of cataracts include: a. aging and steroid therapy.* b. arteriosclerosis. c. hemorrhage. d. iritis.
The alternatives should be grammatically consistent. The answer and distractors should be similar in structure and terminology. Without this consistency in format, the test-taker may be clued to the correct response or know to eliminate some of the options without being familiar with the content. In the sample item below, the student may be clued to the correct answer “a” because it differs grammatically from the others: You are making a home visit with a new mother who is breastfeeding.
She tells you that her nipples are cracked and painful. Which of the following instructions should be given to the mother? to. Put the entire areola in the baby’s mouth during feeding.* b. The baby should be fed less frequently until the nipples are healed. c. There is less chance of cracking if the nipples are washed daily with soap. d. Wiping off the lotion on the nipples before feeding the baby may help.
The alternatives should sample the same domain, for instance, all symptoms, all diagnostic tests, all nursing interventions, varying treatments, and so forth. A study by Ascalon , Meyers, Davis, and Smits (2007) examined the effects on item difficulty of different ways of writing the item stem and homogeneity of the alternatives. They found no differences in item difficulty when the stem was written as a statement versus a question.
However, when alternatives of a multiple-choice item were similar, it increased the item difficulty. It is likely that when responses are dissimilar from the correct response, learners can easily eliminate them as options. In the example that follows, option “b” is not a nursing diagnosis, which may clue the student to omit it as a possibility.
You are working in the Emergency Department, and your patient is having difficulty breathing. His respiratory rate is 40, heart rate 140, and oxygen saturation 90%. He also complains of a headache. Which of the following nursing diagnoses is of highest priority? to. Activity intolerance b. COPD c. Impaired gas exchange* d. Pain
Avoid including opposite responses among the options. This is often a clue to choose between the opposites and not consider the others. A sample item follows: The nurse should determine the correct placement of a nasogastric tube by: a. asking the patient to swallow. b. aspirating gastric fluid from the tube. c. inserting air in the tube and auscultating in the epigastric area.* d. inserting water in the tube and auscultating in the epigastric area.
In this example, the correct response is opposite one of the distractors, which clues the student to select one of these alternatives. In addition, options “c” and “d” begin with “inserting,” which may provide a visual clue to choose between them. McDonald (2007) suggested that when two sets of opposites are used in the alternatives, there is less opportunity for guessing. Using this principle, the first distractor in the example could be reworded to form a second pair of opposites:
The nurse should determine the correct placement of a nasogastric tube by: a. aspirating air from the tube. b. aspirating gastric fluid from the tube. c. inserting air in the tube and auscultating in the epigastric area.* d. inserting water in the tube and auscultating in the epigastric area.
Arrange the options in a logical or meaningful order. The order can be alphabetical, numerical, or chronological ( Gaerson , 1996; Nitko & Brookhart, 2007). Arranging the options in this way tends to randomly distribute the position of the correct response rather than the answer occurring most often in the same location, for example, “b” or “c,” throughout the test. It also helps students locate the correct response more easily when they have an answer in mind.
Options with numbers, quantities, and other numerical values should be listed sequentially, either increasing or decreasing in value, and the values should not overlap. When alternatives overlap, a portion of an option may be correct, or more than one answer may be possible.
These problems are apparent in the sample item that follows:
The normal range for potassium in adults is:
a. 2.5 – 4.5 mEq /L.
b. 0.5 – 3.5 mEq /L.
c. 3.5 – 5.2 mEq /L.*
d. 1.5 – 4.5 mEq /L.
The values in these options overlap, and the alternatives would be easier to review if they were arranged sequentially from decreasing to increasing values. Laboratory and other values should be labeled appropriately, such as hemoglobin 14.0 g/dL. A review of the prior item follows: The normal range for potassium in adults is: a. 0.5 – 1.5 mEq /L. b. 2.0 – 3.2 mEq /L. c. 3.5 – 5.2 mEq /L.* d. 8.5 – 10.3 mEq /L. 8. Each option should be placed on a separate line for ease of student reading.
If answers are recorded on a separate answer sheet, the teacher should review the format of the sheet ahead of time so that responses are identified as “a” through “d” or 1 through 4 as appropriate. Usually items are numbered and responses are lettered to prevent clerical errors when students use a separate answer sheet.
Use the option of “call for assistance” sparingly. Options that relate to getting assistance such as “notify the physician” or “call the supervisor” should be used sparingly because it is not known how they act as distractors in multiple-choice items. McDonald (2007) suggested that students do not readily choose an option such as “call the physician” and therefore it may not be a good distractor.
When it is the correct or best answer, the students would need to weigh that decision against the other options. However, some teacher-made tests may overuse this option as the correct answer, conditioning students to select it without considering the other alternatives. Correct Answer. In a multiple-choice item there is one answer to be selected from among the alternatives.
In some instances the best rather than the correct answer is to be chosen. Considering that judgments are needed to arrive at decisions about patient care, items can ask for the best or most appropriate response from those listed. Best answers are valuable for more complex and higher level learning such as with items written at the application and analysis levels.
Even though best answers require a judgment to select the best option, there can be only one answer, and there should be consistency in the literature and among experts as to that response. A colleague can review the items, without knowing the answers in advance, to ensure that they are correct. Listed below are suggestions for writing the correct answer. These suggestions are guided by the principle that students should not be able to identify the correct response and eliminate distractors because in the way the stem or alternatives are written.
Review the alternatives carefully to ensure that there is only one correct response. For example: Symptoms of increased intracranial pressure include:
- blurred vision.
- decreased blood pressure.
- disorientation.
- increased pulse
In this sample item, both “a” and “c” are correct; a possible review follows: Symptoms of increased intracranial pressure include:
- blurred vision and decreased blood pressure.
- decreased blood pressure and increased pulse.
- disorientation and blurred vision.
- increased pulse and disorientation.
- Review carefully terminology included in the stem to avoid giving a clue to the correct answer.
Key words in the stem, if also used in the correct response, may clue the student to select it. In the following example, “sudden weight loss” is in both the stem and the answer: An elderly patient with sudden weight loss, thirst, and confusion is seen in the clinic. Which of the following signs would be indicative of dehydration?
- Below normal temperature
- Decreased urine-specific gravity
- Increased blood pressure
- Sudden weight loss
The question could be revised by omitting “sudden weight loss” in the stem. An elderly patient with dry skin, thirst, and confusion is seen in the clinic. Which of the following signs would also be indicative of dehydration?
- Below normal temperature
- Decreased urine-specific gravity
- Increased blood pressure
- Sudden weight loss
The correct answer should be randomly assigned to a position among the alternatives to avoid favoring a particular response choice. Some teachers may inadvertently assign the correct answer to the same option (eg, “c”) or, over a series of items, a pattern may develop from the placement of the correct answers (eg, “a, b, c, d, a, b, c, d”). As indicated earlier in the discussion of how to write the options, this potential clue can be avoided by listing the alternatives in a logical or meaningful order such as alphabetical, numerical, or chronological.
However, the teacher should also double check the position of the correct answers on a test to confirm that they are randomly distributed.
The answers should not reflect the opinion of the teacher but instead should be the ones with whom experts agree or with which the most probable responses are. The answers should be consistent with the literature and not be answers chosen arbitrarily by the teacher. Alternatively, a specific authority may be referenced in the stem (eg, “According to the Centers for Disease Control”).
Distractors
Distractors are the incorrect but plausible options offered. Distractors should appeal to learners who lack the knowledge for responding to the question without confusing those who do know the content. If the option is obviously wrong, then there is no reason to include it as an alternative. Because the intent of the distractors is to appeal to learners who have not mastered the content, at least some of the students should choose each option, or the distractors should be revised for the next administration of the test. \
Each alternative should be appropriate for completing the stem. Hastily written distractors may be clearly incorrect, may differ in substance and format from the others, and may be inappropriate for the stem, providing clues as to how to respond. They also may result in a test item that does not measure the students’ learning. When writing a multiple-choice item, it is sometimes difficult to identify enough plausible distractors to have the same number of options for each item on the test.
However, rather than using a filler, which is obviously incorrect or would not be seriously considered by the students, the teacher should use fewer options on that item. Nitko and Brookhart (2007) indicated that there is no rationale for using the same number of alternatives for each item on a test. The goal is to develop plausible and functional alternatives, ones that attract at least some of the students, rather than filler alternatives that no one chooses.
Thus, for some items there may be only three alternatives, even though the majority of questions on that test use four. The goal, however, is to develop three plausible distractors so that most items have at least four responses from which to choose. In writing distractors, it is helpful to think about common errors that students make, phrases that “sound correct,” misperceptions students have about the content, and familiar responses not appropriate for the specific problem in the stem.
Another way of developing distractors is to identify, before writing any of the options, the content area or domain to which all the responses must belong, for example, all nursing interventions. If the stem asks about nursing measures for a patient with acute pneumonia, the distractors might be interventions for a patient with asthma that would not be appropriate for someone with pneumonia.
Terms used in the stem also give ideas for developing distractors. For example, if the stem asks about measures to avoid increasing anxiety in a patient who is delusional, the distractors may be interventions for a delusional patient that might inadvertently increase or have no effect on anxiety, or interventions useful for decreasing anxiety but not appropriate for a patient with a delusional disorder.
Another strategy for developing distractors is to identify the category to which all alternative responses must belong. For a stem that asks about side effects of erythromycin, plausible distractors may be drawn from side effects of antibiotics as a group. Suggestions for writing distractors include: 1. The distractors should be grammatically consistent and should be similar in length, detail, and complexity with each other and the correct answer.
The distractors should be written with the same specificity as the correct response. If the correct response is “quadratus plantae,” distractors that are more general such as “motor” may be a clue not to choose that option. 2. The distractors should sample the same content area as the correct answer. When types of options vary, they can clue the student as to the correct response or to eliminate a particular distractor. In the following example, options “a,” “b,” and “c” pertain to factors in the workplace. Because option “d” relates to diet, it may clue the student to omit it.
A better alternative for “d” would be another factor to assess in the work setting such as how tiring the job is. In planning teaching for a patient with a hiatal hernia, which of these factors should be assessed?
- Amount of lifting done at work.
- Number of breaks allowed.
- Job stress.
- Use of high-sodium foods.
Avoid using “all of the above” and “none of the above” in a multiple choice item. As distractors these contrast with the direction of selecting one correct or best response. With “all of the above” as a distractor, students aware of one incorrect response are clued to eliminate “all of the above” as an option. Similarly, knowledge of one correct alternative clues students to omit “none of the above” as an option.
Teachers resort to “all of the above” when unable to develop a fourth option, although it is often better to rephrase the stem or to modify the options to provide fewer plausible alternatives. McDonald (2007) suggested that the “none of the above” alternative was appropriate for multiple-choice items on calculations.
By using “none of the above,” the teacher avoids giving clues to students when their incorrect answer is not listed with the options. In the following example the student would need to know the correct answer to identify that it is not among the alternatives: You are working in a pediatrician’s office, and a mother calls and asks you how many drops of acetaminophen to give to her infant.
The order is for 40 mg every 12 hours, but the container she has at home is 80 mg/0.8 mL. You should tell the mother to give:
- 1 dropperful
- 1 teaspoon
- 1.5 mL in a 3-mL syringe
- None of the above
Omit terms such as “always,” “never,” “sometimes,” “occasionally,” and similar ones from the distractors. These general terms often provide clues as to the correctness of the option. Terms such as always and never suggest that the alternatives are incorrect because rarely does a situation occur always or never, particularly in patient care.
- Avoid using distractors that are essentially the same. In the following example, alternatives “a” and “c” are essentially the same. If “rest” is eliminated as an option, the students are clued to omit both of these. In addition, the correct response in this item is more general than the others and is not specific to this particular student’s health problems.
A student comes to see the school nurse complaining of a severe headache and stiff neck. Which of the following actions would be most appropriate?
- Ask the student to rest in the clinic for a few hours.
- Collect additional data before deciding on interventions.
- Have a family member take the student home to rest.
- Prepare to take the student to the emergency room. The item could be reviewed as follows:
A student comes to see the school nurse complaining of a severe headache and stiff neck. Which of the following actions would be most appropriate?
- Ask the student to rest in the clinic for a few hours.
- Check the student’s health record for identified health problems.
- Prepare to take the student to the emergency room.
- Send the student back to class after medicating for pain.
Variation of Multiple-Choice
Item Mertler (2003) proposed a variation of the multiple-choice format that combined a multiple-choice item with short-answer or essay. In this format, after answering a multiple-choice item, students develop a rationale for why their answer is correct and the distractors are incorrect. For example: Your patient is ordered 60 mg of Roxanol ™ (morphine sulfate 20 mg/mL) every 4 hours for severe pain. Which of the following actions should be taken?
- Dilute in 500 cc normal saline.
- Give the morphine as ordered.
- Have the pharmacist review the order.
- Call the physician about the dose.
In the space below, provide a rationale for why your answer is the best one and why the other options are not appropriate.
Multiple-Response And Combined-Response
In these item formats several alternatives may be correct, and students choose either all of the correct alternatives (multiple-response) or the best combination of alternatives (combined-response). Multiple-response items are included on the NCLEX Examination as one type of item format (National Council of State Boards of Nursing, 2007).
On the NCLEX and other types of computerized tests, students select all of the options that apply by checking the box that precedes each option, as in the following example: The preliminary diagnosis for your patient, a 20-year-old college student, is meningitis. Which signs and symptoms should you anticipate finding? Select all that apply:
❒ 1. Abdominal tenderness
❒✓ 2. Fever
❒ 3. Lack of pain with sudden head movements
❒✓ 4. Nausea and vomiting
❒✓ 5. Nuchal rigidity
❒✓ 6. Sensitivity to light
❒ 7. Sudden bruising in neck area
Principles For Writing Multiple Choice Questions
The principles for writing multiple-response items are the same as for writing multiple-choice. Additional suggestions for writing combined-response items include the following:
- The combination of alternatives should be plausible. Options should be logically combined rather than grouped randomly.
- The alternatives should be used a similar number of times in the combinations. If one of the alternatives is in every combination, it is obviously correct.Similarly, limited use of an option may provide a clue to the correct combination of responses. After grouping responses, each letter should be counted to be sure that it is used a similar number of times across combinations of responses and that no letter is included in every combination.
- The responses should be listed in a logical order, for instance, alphabetically or sequentially, for ease in reviewing. Alternatives are easier to review if shorter combinations are listed before longer ones.
A sample item follows: Causes of cataracts include:
- Aging.
- Arteriosclerosis.
- Hemorrhage.
- Iritis.
- Steroid therapy.
- 1, 2 b. 1, 5 c. 2, 4 d. 1, 3, 4 e. 2, 3, 5
Conclusion
Multiple-choice items, with one correct or best answer, are used widely in nursing and other fields. This test-item format includes an incomplete statement or question, followed by a list of options that complete the statement or answer the question. Multiple-response items are designed similarly although more than one answer may be correct.
Combined-response items require the student to select one answer with the best combination of alternatives. All of these item formats may be used for evaluating learning at the recall, comprehension, application, and analysis levels, making them adaptable for a wide range of content and learning outcomes. Multiple-choice items are important for testing the application of nursing knowledge in simulated clinical situations and analytical thinking.
Because of their versatility, they can be easily integrated within most testing situations. There are three parts in a multiple-choice item, each with its own set of principles for development:
(a) stem
(b) answer
(c) distractors.
The stem is the lead-in phrase in the form of a question or an incomplete statement that relies on the alternatives for completion. Following the stem is a list of alternatives, options for the learner to consider and choose from. These alternatives are of two types: the answer, which is the correct or best option to answer the question or complete the statement, and distractors, which are the incorrect yet plausible alternatives.
The ability to write multiple-choice items is an important skill for the teacher to develop. This is a situation in which “practice makes perfect.” After writing an item, the teacher should have colleagues read it and make suggestions for revision. The teacher should also try out questions with students and maintain an electronic file of items for use in constructing tests. Although time-consuming to develop, multiplechoice items are an important means for evaluating learning in nursing.