The Test Construction and Preparation of Students for Licensure and Certification Examinations. Teaching Objectives – The first and most important step in test planning is defining and establishing the teaching objectives. Design – The second step is creating the “design.”
Test Construction and Preparation of Students for Licensure and Certification Examinations
Test development for licensing and certification examinations requires a systematic process to ensure validity, reliability, and a fair assessment of candidates’ knowledge and skills. Preparing for these exams involves developing a comprehensive approach, creating different types of questions, and incorporating various assessment techniques.
Test development or construction refers to the science and art of planning, preparing, administering, scoring, statistically analyzing, and reporting test results. There are three common general strategies: inductive, deductive, and empirical. Scales developed today often include elements of all three methods.
Test construction includes task preparation, task analysis, selection of reliable and valid tasks for the final test, and final testing of the reliability and validity of the developed test. Test standardization deals with the development of standards.
What is Licensure and Certification Examinations
One of the outcomes of prelicensure nursing programs is for graduates to pass an examination that measures their knowledge and competencies to engage in safe and effective nursing practice. At the entry level for professional nursing, graduates take the National Council Licensure Examination for Registered Nurses (NCLEX-RN Examination) or, if graduating from a practical or vocational nursing program, they take the National Council Licensure Examination for Practical/Vocational Nurses ( NCLEX-PN Examination).
Certification validates knowledge and competencies for professional practice in a specialized area of nursing. As part of this process nurses may take certification examinations, which assess their knowledge and skills in a nursing specialty such as acute care. There are certification examinations for graduates of associate/diploma, baccalaureate, master’s, and doctoral nursing programs.
At the master’s and doctoral levels, certification examinations measure knowledge and competencies for advanced practice, for teaching, and for administrative roles. As students’ progress through a nursing program, they should have experience with tests that are similar to and prepare them for taking licensure and certification examinations when they graduate.
Because the focus of the NCLEX and most certification examinations is on nursing practice, the other advantage to incorporating items of these types in teacher-made tests is that it provides a way of measuring whether students can apply their theoretical learning to clinical situations. Teachers can develop items that present new and complex clinical situations for students to critically analyze.
Items can focus on collecting and analyzing data, setting priorities, selecting interventions, and evaluating outcomes as related to the content taught in the course. This type of testing is a means of assessing higher and more complex levels of learning and provides essential practice before students encounter similar questions on licensure and certification examinations. Examples are provided of items written at different cognitive levels, thereby avoiding tests that focus only on recall and memorization of facts.
By incorporating items of these types on tests in nursing courses, teachers help students acquire experience with this type of testing as they progress through the program, preparing them for taking licensure and certification examinations as graduates. The reader should keep in mind that presents other ways of assessing higher level learning such as context-dependent testing, case method, and other strategies for evaluating critical thinking.
NCLEX Test Plans
In the United States and its territories, graduates of nursing programs cannot practice as professional nurses or as practical or vocational nurses until they have passed a licensure examination. These examinations are developed by the National Council of State Boards of Nursing, Inc. (NCSBN) based on extensive analyzes of the practice requirements of registered nurses (RNs) and licensed practical nurses (LPNs) or vocational nurses (LVNs). The licensure examination results are then used by the state boards of nursing as one of the requirements for practice in that state or territory.
NCLEX-RN Examination Test Plan
In developing the NCLEX-RN, the NCSBN conducts an analysis of the current practice of newly licensed RNs across clinical areas and settings. This is a continuous process allowing the licensure examination to stay current with the knowledge and competencies needed by entry level nurses. To ensure that the NCLEX-RN measures the essential competencies for practice by a newly licensed RN, the NCSBN reviews the test plan or blueprint every 3 years (Wendt, Kenny, & Anderson, 2007).
For the most recent revision of the test plan, more than 6,000 newly licensed RNs were asked to prioritize how frequently they performed 150 nursing care activities (Wendt et al., 2007). The NCSBN then analyzes those activities in terms of impact on patient safety and settings where they are implemented. A test plan is developed from this analysis, guiding the selection of content and behaviors to be tested and the percentage of items for each of the categories of the test. Each NCLEXRN examination is based on this test plan (Wendt et al., 2007).
Client Needs
Test items on the NCLEX-RN are categorized by client needs: (a) safe and effective care environment, (b) health promotion and maintenance, (c) psychosocial integrity, and (d) physiological integrity. Two of the categories, safe and effective care environment and physiological integrity, also have subgroups. The client needs represent the content tested on the examination.
Safe and Effective Care Environment
In the Safe and Effective Care Environment category, two subcategories of content are tested on the NCLEX-RN:
(a) management of care
(b) safety and infection control
In the management of care subcategory, the questions focus on nursing care and delivery of care that protects patients, families, significant others, and health care providers. Examples of content tested in this category include advance directives, advocacy, case management, collaboration with the interdisciplinary team, concepts of management, confidentiality/information security, delegation, ethical practice, legal rights and responsibilities, performance improvement (quality improvement), resource management , and staff education, among others (Wendt et al., 2007).
In the Safety and Infection Control subcategory, test items focus on prevention of accidents, disaster planning and emergency response plans, ergonomic principles, error prevention, handling hazardous and infectious materials, injury prevention, medical and surgical asepsis, reporting of incidences and irregular occurrences, safe use of equipment, and use of restraints, among others (Wendt et al., 2007).
Health promotion and maintenance
The second category of client needs is Health Promotion and Maintenance. There are no subcategories of needs. Examples of content tested in this category are developmental stages and growth and development, disease prevention, health and wellness, health promotion and screening, immunizations, physical assessment techniques, sexuality, and teaching and learning principles.
Psychosocial Integrity
The third category of client needs, Psychosocial Integrity, also has no subgroups. This category focuses on nursing care that promotes the emotional, mental, and social well-being of patients, families, and others experiencing stressful events, and the care of patients with acute and chronic mental illnesses (Wendt et al., 2007).
Examples of content tested include abuse, behavioral interventions, chemical and other dependencies, cultural diversity, end-of-life care, grief and loss, mental health, psychopathology, sensory and perceptual alterations, and therapeutic communication and environment (Wendt et al., 2007).
Physiological Integrity
The final Client-Needs category, Physiological Integrity, is a significant content area tested on the NCLEX-RN. Items in this category focus on nursing care that promotes physical health and comfort, reduces risk potential, and manages health alterations of patients. Four subcategories of content are examined by these items on the NCLEX-RN examination:
- Basic Care and Comfort: In this area, items focus on comfort measures and assistance with activities of daily living. Related content includes assistive devices, complementary therapies, elimination, mobility and immobility, non-pharmacological comfort interventions, nutrition, palliative care, personal hygiene, and rest and sleep.
- Pharmacological and Parenteral Therapies: Items focus on adverse effects, contraindications, and side effects; blood products and administration; calculating dosages; central venous access devices; medication administration; parenteral/intravenous therapy; pharmacological agents, interactions, and pain management; and total parenteral nutrition.
- Reduction of Risk Potential: The content in this subcategory relates to measures for reducing the risk of developing complications or health problems. For example, items relate to diagnostic tests; laboratory values; potential for complications from tests, treatments, procedures, surgery, and health alterations; and system-specific assessments.
- Physiological Adaptation: The last subcategory, physiological adaptation, includes nursing care of patients with acute, chronic, or life-threatening physical health problems. Sample content areas are alterations in body systems, fluid and electrolyte imbalances, hemodynamics, infectious diseases, management of illness and medical emergencies, pathophysiology, radiation therapy, and unexpected responses to therapies (Wendt et al., pp. 6–8).
Integrated Processes
Four processes are integrated throughout each of the categories of the test plan:
(a) nursing process
(b) caring
(c) communication and documentation
(d) teaching and learning
Thus there can be test items on teaching patients and the nurse’s ethical and legal responsibilities in patient education as part of the Management of Care subcategory, teaching nursing assistants about the use of restraints in the Safety and Infection Control subcategory, health education for different age groups in the Health Promotion and Maintenance category, and discharge teaching in the Reduction of Risk Potential subcategory.
The other processes are integrated similarly throughout the test plan. Many of the items on the NCLEX examinations are developed around clinical situations. Those situations can involve any age group of patients in hospitals, long-term care, community health, or other types of settings.
Cognitive Levels
NCLEX-RN Examination uses Bloom’s taxonomy to develop items. Items are developed at the knowledge, comprehension, application, and analysis levels, with the majority of items at the application and higher cognitive levels (Wendt et al., 2007). This has implications for testing in prelicensure nursing education programs.
Faculty members should avoid preparing only recall and comprehension items on their tests. Although some low-level questions are essential to assess knowledge and understanding of facts and basic principles, test items also need to ask students to use their knowledge and think critically to arrive at an answer. Test blueprints can be developed to list not only the content and number of items in each content area but also the level of cognitive complexity at which items should be written.
NCLEX-PN Examination Test Schedule
The test plan for the NCLEX-PN is developed and organized similarly to the RN examination. For the 2008 test plan, practical and vocational nurses who were newly licensed were asked how frequently they performed 147 nursing activities and the priority of these activities (NCSBN, 2007, p. 3). Those activities were then used as the framework for the development of the test plan for the PN examination. The test plan is structured around client needs and integrated processes fundamental to the practice of practical and vocational nursing.
The same four client needs categories are used for the NCLEX-PN examination with differences in some of the subcategories, related content, and percentage of items in each category and subcategory. Similar to the NCLEX-RN Examination, four processes are integrated throughout the test:
(a) the clinical problem-solving process (nursing process)
(b) caring
(c) communication and documentation
(d) teaching and learning.
Items are developed at all cognitive levels with the majority written at the application or higher levels of cognitive abilities, consistent with the NCLEX-RN Examination test plan (NCSBN, 2007).
Types of Items on the NCLEX Examinations
The NCLEX examinations contain the standard four-option multiple choice items and alternate item formats. Earlier described how to construct each type of item used on the NCLEX: multiple-choice ; and the alternate formats of multiple-response , fill-in-the-blank and drag-and-drop , and hot-spot and chart/exhibit .
The NCLEX-RN Detailed Test Plan provides valuable information about the practice activities used for developing the items and content areas assessed in each of the categories and subcategories on the examination. As described earlier, the NCSBN analyzes the current practices of newly licensed RNs and PNs/VNs across clinical specialties and settings.
This analysis identifies nursing activities that are used frequently by entry-level nurses and are important to ensure patient safety. Development of the NCLEX examinations using these practice activities provides evidence of reliability and validity to support the use of the NCLEX as a measure of competent entry-level nursing practice (Wendt et al., 2007, p. 9).
The NCLEX-RN Detailed Test Plan includes a list of the activity statements and related content for each category and subcategory. This information is of value in developing items for testing in a nursing program. For example, in the Safety and Infection Control subcategory, the activity statements describe the practices that RNs use to protect patients and others from health and environmental hazards.
An example of one of these activity statements is: “Apply principles of infection control (eg, hand hygiene, room assignment, isolation, aseptic/sterile technique, universal/standard precautions)” (p. 9). A sample test item also is provided with each category and subcategory. The sample item in the Safety and Infection Control subcategory assesses student understanding about teaching a patient with neutropenia how to avoid infections. In the NCLEX-PN Test Plan, the categories and subcategories are described with related content areas.
Administration of NCLEX Examinations
The NCLEX examinations are administered to candidates by computerized adaptive testing (CAT). The CAT model is such that each candidate’s test is assembled interactively as the person is answering the questions. Each item on the NCLEX has a predetermined difficulty level. As each item is answered, the computer re-estimates the candidate’s ability based on whether the answer is correct or incorrect. The computer then searches the item bank for an item with the same degree of difficulty (NCSBN, 2007; Wendt et al., 2007).
This is an efficient means of testing, avoiding questions that do not contribute to determining a candidate’s level of nursing competence. The standard for passing the NCLEX is criterion-referenced. The standard is set by the NCSBN based on an established protocol and is used as the basis for determining if the candidate has passed or failed the examination.
The NCLEX-RN can range from 75 to 265 items, with 15 of those being pretest items, which are not scored. After candidates answer the minimum number of items, the testing stops when the candidate’s ability is above or below the standard for passing, with 95% certainty (Wendt et al., 2007).
Because the NCLEX is an adaptive test, candidate’s complete different numbers of items, and therefore the test takes varying amounts of time. The examination stops when the maximum number of items has been taken or when the time limit has been reached.
All RN candidates must answer a minimum number of 75 items. The maximum number they can answer is 265 within a time limit of 6 hours (NCSBN, nd ). On the NCLEX-PN, practical and vocational nursing candidates must answer a minimum of 85 items. The maximum number of items they can answer is 205, allowed during the 5-hour testing period (NCSBN, 2007).
Preparation Of Items At Different Cognitive Levels
When courses have higher level outcomes, tests in those courses need to measure learning at the application and analysis levels rather than at recall and comprehension. Items at higher levels of cognitive complexity are more difficult and time-consuming to develop, but they provide a way of evaluating ability to apply knowledge to new situations and to engage in analytical thinking.
Items at these higher levels can be used to assess critical thinking (McDonald, 2007; Morrison & Free, 2001). The majority of items on the NCLEX are written at higher levels of cognitive ability, requiring complex thought and problem solving. Students are at a disadvantage if they encounter only recall and comprehension test items as they progress through a nursing program.
Low-level items assess how well students memorize specific information, not if they can use that knowledge to analyze clinical situations and arrive at the best decisions possible for those situations. Students need experience answering questions at the application and analysis levels before they take the NCLEX. Morrison (2005) emphasizes that content-oriented test items at the knowledge level do not prepare students to take the NCLEX-RN.
More important, if course outcomes are at higher levels of cognitive complexity, then tests and other methods need to assess learning at those levels. In graduate nursing programs, test items should be developed at higher cognitive levels to assess students’ ability to problem solve and think critically and to prepare them for certification examinations they might take as graduates.
When developing a new test, a blueprint is important in planning the number of items at each cognitive level for the content areas to be assessed. By using a blueprint, teachers can avoid writing too many recall and comprehension items. For existing tests that were not developed using a blueprint, teachers can code items using Bloom’s taxonomy and then decide if higher level items should be added.
Knowledge or Recall
In developing items at varying cognitive levels, it is important to remember the learning outcome intended at each of these levels. Questions at the knowledge level deal with facts, principles, and other specific information that is memorized and then recalled to answer the item. An example of a multiple-choice item at the knowledge level follows:
Your patient is taking pseudoephedrine for his stuffy nose. Which of the following side effects is common among patients using this medication?
a. Diarrhea
b. Dyspnea
c. Hallucinations
d. Restlessness
Comprehension
At the comprehension level, items assess understanding of concepts and ability to explain them. These questions are written at a higher level than recall, but they do not assess problem solving or use of information in a new context. An example of an item at the comprehension level is: An adult female patient is a new admission with the diagnosis of acute renal failure. Her total urine output for the previous 24 hours was 90 mL. A urinary output of this amount is known as…………
Application
At the application level, students apply concepts and theories as a basis for responding to the item. At this level, test questions measure use of knowledge in new or unique situations. One method for developing items at this level is to prepare stems that have information that students did not encounter in their learning about the content.
The stem might present patient data, diagnoses, or treatments different from the ones discussed in class or in the readings. If examples in class related to nursing care of adults, items might test ability to use those concepts when the patient is an adolescent or has multiple co-existing problems. An example of an item at the application level is:
A mother tells you that she is worried about her 4-year-old daughter’s development because her daughter seems to be “behind.” You complete a developmental assessment. Which of the following behaviors suggests the need for further developmental testing?
- Cannot follow 5 commands in a row
- Has difficulty holding a crayon between thumb and forefinger
- Is unable to balance on each foot for 6 seconds
- Keeps making mistakes when asked about the day of the week
Analysis
Questions at the analysis level are the most difficult to construct. They require analysis of a clinical or other situation to identify critical elements and relationships among them. Items should provide a new situation for students to analyze, not one encountered previously for which the student might recall the analysis. Many of these items require learners to solve a problem and make a decision about priorities or the best approach to take among the options.
Or, items might ask students to identify the most immediate course of action to meet patient needs or manage the clinical situation. The difference between application and analysis items is not always readily apparent. Analysis items, though, should ask students to identify relevant data, critical elements, component parts, and their interrelationships.
In analysis level items students should distinguish between significant and no significant information and select the best approach or priority among those cited in the alternatives. An example of an item written at the analysis level is:
You receive a report on the following patients at the beginning of your evening shift at 3 pm Which patient should you assess first?
- An 82-year-old with pneumonia who seems confused at times
- A 76-year-old patient with cancer with 300 mL remaining of an intravenous infusion
- A 40-year-old who had an emergency appendectomy 8 hours ago
- An 18-year-old with chest tubes for treatment of a pneumothorax following an accident
Testing In the Nursing Process Framework
One of the processes integrated into the NCLEX test plans is the nursing process. This is also a framework taught in many nursing programs. If not presented as a series of stages, most clinical courses address, in some form, assessment, data analysis, diagnoses, interventions, and evaluation. For this reason another useful framework for developing test questions is the nursing process.
Items can examine assessment of patients with varied needs and health problems, analysis of data, nursing and other diagnoses, priorities of care, nursing interventions, treatments, and evaluation of the outcomes of care. Current practices suggest that many test items focus on scientific rationale, principles underlying patient care, and selection of interventions.
Fewer items are developed on collecting and analyzing data, determining nursing diagnoses and patient problems, setting priorities and realistic goals of care, and evaluating the effectiveness of interventions and outcomes. Developing items on the nursing process and based on clinical scenarios provides an opportunity to examine these outcomes of learning.
McDonald (2007) identified another advantage of nursing process testing as promoting the development of unique situations, which then allows for testing at a higher cognitive level. Although nursing process items can be written at the recall level, they are more appropriate for testing of more complex cognitive outcomes.
Writing Items in Framework of the Nursing Process
The procedure of developing nursing process items begins with identifying the total number of items to be written. This includes specifying the number of items for each phase of the nursing process. On some tests, greater weight may be given to certain phases of the process, for example, assessment, if these were emphasized in the instruction.
As part of this planning, the teacher also maps out the clinical situations to be tested as relevant to course content. For instance, the teacher may plan for two assessment items on pain; three intervention items, including two on nursing interventions with their related evidence and a third on medications; and one item on evaluating the effectiveness of pain management with children.
A similar process may be used with other content areas for which this type of testing is intended. Items may stand alone, or a series of items may be developed related to one clinical scenario. In the latter format the teacher has an option of adding data to the situation and creating an unfolding case, which was discussed.
Test items on assessing examine knowledge of data to collect, use of varied sources of data, relevance of selected data for a patient, verifying data, communicating information, and documenting findings. Analysis items (referring to the nursing process, not the analysis level in Bloom’s taxonomy) measure ability to interpret data, identify patient problems and needs, and determine nursing diagnoses.
Items on planning focus on identifying priorities, planning nursing measures to achieve outcomes of care, selecting effective interventions, and collaborating with others in developing interdisciplinary plans. Implementation items relate to the principles underlying nursing and other interventions, effectiveness of interventions, the evidence base for interventions, priorities of care, and documentation.
The last phase for which items may be written is evaluation. These items focus on patients’ responses to care, the extent to which outcomes have been achieved, variables influencing care delivery, recording patient progress and outcomes, and needed revisions of the plan of care.
Examples of stems that can be used to develop items about the nursing process are provided in Exhibit 8.1. McDonald (2007) referred to these sample stems as “item shells.” Teachers can select a stem and add content from their own course, providing an easy way of writing items on the nursing process. Sample items for each phase of the nursing process follow.
Assessment
An 8-year-old boy is brought to the emergency room by his mother after falling off his bike and hitting his head. Which of the following data is most important to collect in the initial assessment?
- Blood pressure
- Level of consciousness
- Pupillary response
- Respiratory status
Analysis
A 17-year-old adolescent girl is seen in the clinic for pelvic inflammatory disease. The nurse should anticipate which of these nursing diagnoses?
- Altered health maintenance
- Knowledge deficit
- Pain
- Sexual dysfunction
Planning
Your patient is being discharged after a sickle cell crisis. Which of the following measures should be included in your teaching plan for this patient? Select all that apply.
❒ 1. Avoid warm temperatures inside and outdoors
❒ 2. Do not use any steroidal anti-inflammatory drugs (NSAIDs) for pain
❒✓ 3. Drink at least 8 glasses of water a day
❒✓ 4. Eat plenty of grains, fruits, and green leafy vegetables
❒✓ 5. Get a vaccination for pneumonia
❒ 6. Keep cold packs handy for joint pain
Implementation
Your patient is in active labor with contractions every 3 minutes lasting about 1 minute. She appears to have a seizure. Which of the following interventions is the top priority?
- Assess her breathing pattern.
- Attach an external fetal monitor.
- Call the physician.
- Prepare for a cesarean delivery
Evaluation
A male adult patient was discharged following a below-the-knee amputation. You are making the first home health visit after his discharge. Which of the following statements by the patient indicates that he needs further instruction?
- “I know to take my temperature if I get chills again like in the hospital.”
- “I won’t exert myself around the house until I see the doctor.”
- “The nurse said to take more insulin when I start to eat more.”
- “The social worker mentioned a support group. Maybe I should call about it.”
Preparation Of Students For The Nclex Examinations
A number of studies have been done over the years to identify predictors of success on the NCLEX-RN. Some factors related to performance on the NCLEX-RN are: SAT scores (Crow, Handley, Morrison, & Shelton, 2004); scores on exit or prelicensure readiness examinations (Beeson & Kissling , 2001; Frith , Sewell, & Clark, 2006; Morrison, Adamson, Nibert , & Hsia, 2004; Morrison, Free, & Newman, 2002; Nibert , Young, & Britt, 2003); grades in nursing courses and graduation grade point average (Beeman & Waterhouse, 2001; Beeson & Kissling , 2001; Stuenkel , 2006; Tipton et al., 2008); and grades in science courses (Abbott, Schwartz, Hercinger , Miller, & Foyt , 2008).
Academic achievement, in terms of nursing course grades and overall grade point average, has been found across studies as predictive of student performance on the NCLEX-RN. Other nursing educators have examined nonacademic factors that might influence performance on the NCLEX. It is critical for students to be prepared for the NCLEX and believe they are “ready” to take it. New graduates should be encouraged to study intensively for the examination.
In a study by Beeman and Waterhouse (2003), the total number of hours studied correlated with passing the NCLEX. A second area of the literature on the NCLEX-RN focuses on methods of preparing students to pass the examination. One development in this area has been the use of standardized examinations designed to predict student performance on the NCLEX-RN.
A number of companies publish standardized tests that are intended to measure students’ readiness for the NCLEX. By analyzing the results of standardized tests for NCLEX readiness, faculty members and students can work together to design individual plans for remediation so that students will be more likely to experience first-time success on the licensure examination.
Anderson (2007) described an approach in which faculty members work with students on an individual basis to develop a plan for studying and preparing for the NCLEX. The plan is based on the student’s personal areas of weakness. This initiative has resulted in an increase in NCLEX passing rates.
Other approaches such as self-assessment of content areas needing improvement, test-taking tips, managing test anxiety, cooperative study groups, commercial test preparation courses, and careful planning for the day of testing have been used by nursing faculty to assist students in preparing for the NCLEX examinations (Anderson, 2007; Crow et al., 2004; Cunningham, Stacciarini , & Towle , 2004; Frith et al., 2006; McQueen, Shelton, & Zimmerman, 2004; Poorman , Mastorovich , & Molcan , 2007; Stark, Feikema , & Wyngarden , 2002).
Frith et al. (2006) described the development of a new course, Integrated Clinical Concepts, designed to support and prepare students for the NCLEX. This one-credit course includes review of content on the NCLEX, test-taking strategies, and practice items.
The course also provides support for students and addresses test anxiety and other issues that might influence success on the examination. Experience with test items that are similar to the NCLEX prepares students for the types of items they will encounter on the licensing examination. In addition to these item formats, students also need experience in taking practice tests.
Conclusion
One of the principles emphasized was the need to prepare items at different cognitive levels as indicated by the outcomes of the course. Items at the recall level assess how well students memorized facts and specific information; they do not, however, provide an indication of whether students can use that information in practice or can engage in analytical or higher level thinking. To assess those higher level outcomes, items must be written at the application or analysis levels or evaluated by methods other than tests.
It is worthwhile for faculty members to develop a test blueprint that specifies the number of items to be developed at each cognitive level for content areas in the course. By using a blueprint, teachers can avoid writing too many recall and comprehension items on an examination.
As students’ progress through a nursing program, they develop abilities to assess patients with varied needs and health problems, analyze data and derive multiple nursing diagnoses, set priorities for care, critique nursing interventions and select appropriate ones, and evaluate the effectiveness and outcomes of care.
Testing within the framework of the nursing process provides an opportunity to assess those learning outcomes. Items may be written about phases of the nursing process, decisions to be made in clinical situations and consequences of each, varying judgments possible in a situation, and other questions that examine students’ thinking and clinical judgment as related to the situation described in the item .
This format of testing also provides experience for students in answering the types of items encountered on licensure and certification examinations.
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