5
MULTIPLE-CHOICE AND MULTIPLE-RESPONSE
This chapter focuses on two other kinds of selected-response items: multiple-choice and multiple-response. Multiple-choice items, which have one correct or one best answer, are used widely in nursing and in other fields. This test-item format includes a question or incomplete statement, followed by a list of options that answer the question or complete the statement. 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 remembering, understanding, applying, and analyzing levels, making them adaptable for a wide range of content and learning outcomes. Appendix A provides a quick reference guide to writing multiple-choice and multiple-response items and some examples of these items.
Multiple-Choice Items
Multiple-choice items can be used for assessing many types of outcomes. Some of these include
• Knowledge of facts, specific information, and principles
• Definitions of terms
• Understanding of content and concepts
• Application of concepts to patient scenarios
• Analysis of data and clinical situations
• Comparison and selection of varied treatments and interventions
• Judgments and decisions about actions to take in clinical and other situations
Multiple-choice items are particularly useful in nursing to assess outcomes that require students to apply knowledge and analyze data and situations. With multiple-choice items, the teacher can introduce new information requiring application of concepts and theories or analytical thinking to respond to the questions. Experience 80with multiple-choice testing provides essential practice for students who will later encounter this type of item on licensure, 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.
Although there are many advantages to multiple-choice testing, there are also 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 remembering and understanding. Second, teachers often have 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 applying and analyzing levels require use of knowledge and analytical thinking to make a selection from the available options. For items at higher cognitive levels, test-takers need to compare options and make a judgment about the correct or best response. Pham et al. (2018) found that multiple-choice items can test higher level learning as well as short-answer items.
Writing Multiple-Choice Items
There are three parts to a multiple-choice item, each with its own set of principles for development: (a) stem, (b) answer, and (c) distractors. Table 5.1 indicates each of these parts.
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, also called the keyed response, 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.
81TABLE 5.1 Parts of a Multiple-Choice Item
| AN EARLY AND COMMON SIGN OF PREGNANCY IS | STEM IN FORM OF INCOMPLETE STATEMENT |
|---|---|
| OPTIONS OR ALTERNATIVES | |
a. Amenorrhea b. Morning sickness c. Spotting d. Tenderness of the breasts | Answer Distractor Distractor Distractor |
| IN WHICH OF THE FOLLOWING GROUPS DOES RAYNAUD’S DISEASE OCCUR MOST FREQUENTLY? | STEM IN FORM OF QUESTION |
| OPTIONS OR ALTERNATIVES | |
a. Men between 20 and 40 y old b. Men between 50 and 70 y old c. Women between 20 and 40 y old d. Women between 50 and 70 y old | Distractor Distractor Answer Distractor |
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, after reading the stem, the learner should understand the intent of the item and what type of response the teacher expects (Brookhart & Nitko, 2019). 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 assessed. Guidelines for writing the stem are as follows:
1. 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:
82Cataracts:
a. are painful.
b. may accompany coronary artery disease.
c. occur with aging.
d. result in tunnel vision.
The stem of this question does not 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. Also, the keyed response implies that aging is the only cause of cataracts, which is not accurate and may confuse students who know the content well. 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 should 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, “Which 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.
2. 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:
83You 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 (see Chapter 7, Assessment of Higher Level Learning).
Stems also should 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.
3. 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 an opacity of the lens or capsule of the eye leading to blurred and eventual loss of vision. The causes of cataracts include:
a. aging.
b. arteriosclerosis.
c. hemorrhage.
d. iritis.
4. 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:
a. is amenorrhea.
b. is morning sickness.
c. is spotting.
d. is tenderness of the breasts.
84The word is may be moved to the stem:
An early and common sign of pregnancy is:
a. amenorrhea.
b. morning sickness.
c. spotting.
d. 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:
a. decreased perspiration, tremors at rest, and muscle rigidity.
b. increased salivation, muscle rigidity, and diplopia.
c. muscle rigidity, decreased salivation, and nystagmus.
d. 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?
a. Decreased salivation and nystagmus.
b. Increased salivation and diplopia.
c. Tremors at rest and decreased perspiration.
d. Tremors during activity and increased perspiration.
5. 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 told recently that he has cataracts. The causes of cataracts include:
a. aging.
b. arteriosclerosis.
c. hemorrhage.
d. iritis.
In this item, informing the student that the patient is elderly provides a clue to the correct response.
6. 85Avoid 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, completion, or multiple response. If a negatively phrased item must be used, the negative word should be only in the stem or only in an alternative, but not in both of them, and the negative word should be underlined or placed in CAPITAL LETTERS (Brookhart & Nitko, 2019).
7. The stem and alternatives that follow should be consistent grammatically. 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 her 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 revised 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.
8. 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,
86Narrowing 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.
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