Objective One

Developing Multiple-Choice Items

Develop a Style Guide for Multiple-Choice Item Development

An Overview

Mary E. McDonald memcd@aol.com Educational Assessment Strategies, LLC

Item Development

Item Development

General Guidelines
Identify the domain you are measuring Select the item format that best suits the domain

Multiple-Choice Format
Allows broad content sampling Widely used on standardized exams Widely used on nursing classroom exams

Multiple-Choice
Stem presents the problem Question A nurse should assess a client who has Parkinsons disease for which of these manifestations? Completion A nurse should assess a client who has Parkinsons disease for Options propose the answers Key Distractors

Multiple-Choice Format
A nurse should assess a client who has Parkinsons disease for which of these manifestations? A. Impaired vision (Distractor) B. Shuffling gait (Key) C. Orthostatic hypotension (Distractor) D. Urinary retention (Distractor)

Preferred Format
Clarity is the key issue The question format is preferred Use the format that presents the problem most clearly

Style Guidelines
Select client or patient Client who has a disease Avoid passive voice A client has been taught by a nurse Use present tense A nurse is teaching a client Use third person Nurse not You Use should not would Should denotes obligation Would suggests what might happen

Style Guidelines
Use milliliters (mL) for fluids not cc Spell out all terms when first referenced with abbreviation in parenthesis nasogastric tube (NGT) use abbreviation on 2nd abbreviation not needed if term only used once in stem Use both generic and brand name for medications digoxin (Lanoxin) Label all lab values and vital signs

Label Values
A client has a blood pressure of 120/80, a pulse of 86, respirations of 22 and an oral temperature of 99 0.

Label Values
A client has a blood pressure of 120/80, a pulse of 86, respirations of 22 and an oral temperature of 99 0. A client has a blood pressure of 120/80 mm Hg, a pulse of 86/min, respirations of 22/min and an oral temperature of 99 0F (37.2 0C).

Style Guide

Usemanifestations instead of signs and/or symptoms

Manifestations
A nurse should monitor a client who is taking digoxin (Lanoxin) for which of these symptoms? A. Gastric upset. B. Lower extremity edema. C. Double vision. D. Slowed capillary refill.

Manifestations
A nurse should monitor a client who is taking digoxin (Lanoxin) for which of these manifestations? A. Gastric upset. B. Lower extremity edema. C. Double vision. D. Slowed capillary refill.

Stems
Use complete stems and short options
Central idea and most of phrasing in stem Should not have to read the options to understand the question

Stems
Concept being tested should be stated in the stem One problem

What is the problem or potential problem?

Incomplete Stems
Confusion results when the direction of question unclear
The thyroid gland is Polydipsia, polyuria, and edema are All of the following are true of enzymes except

Undirected Stem
Dehydration A. leads to postural hypotension. B. results in hyponatremia. C. causes Kussmaul breathing. D. is associated with bradycardia.

Undirected Stem
Is this information clinically relevant? How can the question be posed in a clinical setting?

Directed Stem
Dehydration A. leads to postural hypotension. B. results in hyponatremia. C. causes Kussmaul breathing. D. is associated with bradycardia. Which of these client manifestations should indicate to a nurse that a client may be developing fluid volume deficit? A. Bradycardia. B. Hyponatremia. C. Postural hypotension. D. Kussmaul breathing.

Undirected Stem
Steroids a. b. c. d. can cause immunosuppression. increase metabolism. alter pulmonary function. are a risk for renal shutdown.

Undirected Stem
Is this information clinically relevant? How can the question be posed in a clinical setting?

Directed Stem
Steroids a. can cause immunosuppression. b. increase metabolism. c. alter pulmonary function. d. are a risk for renal shutdown. Which of these instructions should a nurse give to a client who is taking an oral steroid? a. Call your doctor if you develop a sore throat. b. This medication may cause you to lose weight. c. Urinary problems are common with this medication. d. Record your pulse every day and bring the list to your next doctors appointment.

SuccinctStems
The key to writing effective stems is to specify all of the conditions necessary to solve the problem in the stem, while excluding any unnecessary information

Allow the Student to Focus on the Problem

Succinct Stems
All information should be germane to the question or one of the options Remove all extraneous information age/unless relevant gender/remove pronouns names

Succinct/Complete Stems
A 42-year-old male accountant who had surgery to repair an abdominal hernia has been assessed by a nurse. A nurse is assessing a client who had surgery to repair an abdominal hernia 4-hours ago.

Avoid Ambiguity
Ambiguity causes confusion Communicate succinctly and precisely

Ambiguous
A client with hepatic cirrhosis has repeated massive paracentesis. Which concurrent nursing implementation will be most effective in reducing recurrence of ascitic fluid with fewest complications? A. Administer salt poor albumin intravenously * B. Restrict dietary intake of protein foods C. Administer thiazide diuretics by mouth. D. Encourage upright posture and mobility as tolerated.

Students should spend time reasoning out the answer NOT Trying to figure out what the question is asking

Avoid Ambiguity

Revision
A client who has hepatic cirrhosis had several paracenteses over the last month with repeated recurrence of ascites. The client has all of these prescriptions. A nurse should recognize that which one will most effectively decrease the recurrence of ascites? A. Administer intravenous salt poor albumin to the client. * B. Restrict the clients dietary intake of protein. C. Administer the oral diuretic to the client. D. Maintain the client on bedrest.

Is this question testing an important concept? How can I state the problem clearly? Can I format the question so it is clinically relevant?

Grammatically Correct
Essential for clarity Increases face validity Decreases confusion and improves reliability

Grammatically Incorrect
A nurse is caring for a client post gastric resection with a nasogastric tube.

Grammatically Correct
A nurse is caring for a client post gastric resection with a nasogastric tube. A nurse is planning care for a client who had a gastric resection and has a nasogastric tube connected to continuous suction.

Grammatically Incorrect
When assessingthe health needs of a community a nurse should consider that spiritually refers to an A. participation in an organized religious group. B. practices and rituals of a particular religion. C. dimension that is outside of the realm of health . D. individuals beliefs about the meaning of life and death. *

Run-On Sentence/Missing Info

A 16-year-old patient who has sustained a maxillofacial wound without airway compromise and shallow cut to her forearm with a positive radial pulse from the result of a wall falling on her, while taking cover in her bathroom during a tornado, would be triaged at the site of injury as: a. Expectant b. Delayed * c.Immediate d. Minimal

Run-on-Sentence

Is this question testing an important concept? How can I state the problem clearly? Can I format the question so it is clinically relevant?

Run-On Sentence
A nurse is triaging patients at a community hospital where a tornado caused devastating damage 2-hours ago. Which of these patients should be triaged as delayed? (immediate?) a. A 16-year-old patient who sustained a maxillofacial abrasion b. A 42-year-old patient who ... c.A 65-year-old patient who .. d. A 76-year-old patient who ..

Grammatically Incorrect/Misuse of Terms

You are teaching a health class at a senior citizen center on the early detection and screening of prostrate cancer. You evaluate that the men in the group have understood your instructions when theystate which of the following? a. I should have a PSA test done yearly. b. I should have a digital rectal examination done yearly. c. Ishould have a PSA test and a digital rectal examination done yearly. d. I dont need a screening unless I develop symptoms.

Gramatically Incorrect

Grammatically Incorrect Revision

Which of these statements, if made by a 53-year-old client, indicates that the client correctly understands screening recommendations for prostate cancer? A. If my annual rectal exam is normal I will not need to have a PSA test. B. I will need to start having PSA testing every year after my 60th birthday. C. I will have a PSA test and a digital rectal examination done yearly. * D. If I develop difficulty voiding or blood in my urine I will have a PSA test.

Is this question testing an important concept? How can edit the item so it is grammatically correct? Can I format the question so it is clinically relevant and challenging?

Negative Stem
Correct answer has to be an incorrect statement Use a negative stem only when knowing what not to do is important Increases confusion and decreases reliability HighlightonlyNEGATIVE words

Negative Stem
A nurse is assessing a client who has pneumonia. Which of these assessment findings indicates that the client does NOT need to be suctioned? A. Diminished breath sounds. B. Absence of adventitious breath sounds.* C. Inability to cough up sputum. D. Wheezing following bronchodilator therapy.

Negative Stem

Positive Stem
A nurse is assessing a client who has pneumonia. Which of these assessment findings indicates that the client does NOT need to be suctioned? A.Diminished breath sounds. B.Absence of adventitious breath sounds.* C. Inability to cough up sputum. D. Wheezing following bronchodilator therapy.

Is this question testing an important concept? How can I state the problem positively? Can I format the question so it is clinically relevant?

Which of these assessment findings, if identified in a client who has pneumonia, indicates that the client needs to be suctioned? A. Absence of adventitious breath sounds. B. Respiratory rate of 18 breaths per minute. C. Inability to cough up sputum D. Wheezing prior to bronchodilator therapy.

Negative Stem
A nurse reviews self care with a client who had a cataract extracted from the right eye this morning. Which of these statements, if made by the client, indicates that the client needs FURTHER instruction?
A. B. C. D. I will avoid becoming constipated. I can take a short walk with my wife. I will stay on bedrest for three days. * I can watch the football game on television.

Homogenous Options

Correct answers and distractors should be equally attractive to the uninformed Write stem and correct answer first then model distractors after correct answer

Homogeneity

Heterogeneous Options
A nurse is assessing a client who has skeletal traction applied to the right leg. The nurse observes that the client has pallor of the right foot, slow capillary refill, and a weak dorsalispedis pulse. Which of these actions should the nurse take? A. B. C. D. Elevate the right leg. Notify the physician. * Decrease the traction. Apply heat to increase capillary dilation.

Heterogeneous options provide cues All responses should be parallel in length, style, grammatical structure, and complexity Students will choose the heterogeneous option

Heterogeneous Option

Homogeneous Options/Best Answer

A nurse is assessing a client who has skeletal traction applied to the right leg. The nurse observes that the client has pallor of the right foot, slow capillary refill, and a weak right dorsalispedis pulse. Which of these actions should the nurse take? A. B. C. D. Elevate the right leg. Notify the physician. * Decrease the traction. Apply heat to the right leg.

Is this question testing an important concept? How can edit the option so it appears similar to the other options? Can I format the question so it is clinically relevant and challenging?

Plausibility
Incorrectness is not enough Well constructed multiple-choice item will require students to discriminate between plausible answers Plausible distractors look attractive to the uninformed

Plausibility
Which of these questions should a nurse ask a client who has sustained a head injury? A. Did blood from the other victim touch you? B. Do you have a familial tendency for migraine headaches? C. Is your throat red? D. Did you lose consciousness at any time after the accident? *

Heterogeneous Option

Plausibility
Which of these questions should a nurse ask a client who was in an automobile accident and has a bleeding head wound? A. Have you ever had a blood transfusion?

Is this question testing an important concept? How can edit the distractors so they appear plausible to the uninformed? Can I format the question so it is clinically relevant and challenging?

B. What is your resting pulse rate and blood pressure? C. Did the driver of the other vehicle appear to be intoxicated? D. Did you lose consciousness at any time after the accident? *

Action in the Stem

Actions belong on the options
An action in the stem promotes guessing Student should determine which action is correct

Action in the Stem

An intravenous heparin lock is inserted into the right arm of a 68 year old male client to maintain an access site for parenteral medication administration. When administering a medication via an intravenous heparin lock a nurse should flush the lock with A. 2.5 mL of bacteriostatic water1 B. 10 mL of 5% dextrose solution 1 C. 2.5 mL of normal saline 94 D. 1 mL of atropine sulfate1

Action in the Stem

Is this question testing an important concept? How can I edit the stem and the options so the options are actions and the problem is stated in the stem. Can I format the question so it is clinically relevant and challenging?

Action in the Stem

Which of these actions should a nurse take immediately before administering a medication to a client who has an intravenous heparin lock in the right arm? A. Apply iodine to the lock insertion site B. Aspirate the lock to check for blood return C. Flush the lock with 2.5 ml of normal saline D. Elevate the right arm above the level of the heart

Action in the Stem

A patient with CHF is displaying symptoms such as dry hacking cough, fatigue, and a slight increase in todays weight. The most appropriate position for the patient to be placed in is: A. supine. B. low Fowlers. C. high Fowlers with feet dangling. D. left lateral with head elevated.

Action in the Stem

Is this question testing an important concept? How can I edit the stem and the options so the options are actions and the problem is stated in the stem. Can I format the question so it is clinically relevant and challenging?

Actions in the Options

A nurse is planning care for a patient who has congestive heart failure. The nurse assesses that the patient gained one pound in 24 hours, has a dry, hacking cough, and is very fatigued. Which of these actions should the nurse take? A. Keep the patients feet elevated on two pillows B. Administer the patients prescribed cough suppressant C. Assist the patient to maintain a high Fowlers position D. Restrict the patients oral fluid intake

Objective Two

Develop Items that Assess Higher-Order Thinking

Higher-Order Thinking

Cognitive Levels for Item Writing

Knowledge Comprehension Application Analysis

Mans mind stretched to a new idea never goes back to its original dimensions.

Oliver Wendell Holmes

Knowledge
The dose of intravenous heparin should be adjusted to maintain the clients activated partial thromboplastin time (APTT) at how many times the control? A. Less than 1.5 B. Between 1.5 and 2.5 * C. Greater than 2.5 and less than 3.5 D. Between 3.5 and 4.5

Comprehension
A nurse reviews medication precautions with a client who is taking wafarin sodium (Coumadin). Which of these statements, if made by the client, would indicate that the client has the correct understanding of the instructions? A. Ill rotate the injection site for the medication every day. B. Ill eat spinach once each week until I finish taking this medication. * C. I can expect to have red tinged urine while taking this medication. D. I will weigh myself every morning while Im taking this medication.

Student must identify the range for the desired APTT . Requires only memorization. No judgment needs to be made.

Requires understanding of precautions related to Coumadin to translate meaning of the clients statement

Application
A client who is receiving intravenous heparin has an activated thromboplastin time (APTT) of two and one-half times the control. In addition to documenting the finding, which of these actions should a nurse take? A. Call the lab for a stat repeat of the test. B. Discontinue the heparin infusion immediately. C. Continue to monitor the client. * D. Call the blood bank for a unit of packed cells. Requires recognition of the range for the desired APTT and also decision making skills to select the appropriate nursing intervention.

Analysis
A nurse is responsible for the care of several clients. Which of these tasks would be appropriate to assign to an unlicensed care giver? A. Monitoring the chest tube drainage for a 28-year-old client. B. Teaching a 46-year-old client how to use a blood glucose meter. C. Checking the flow rate of a tube feeding for a 68-year-old client. D. Feeding a 92-year-old client who is disoriented. *

This item requires the student to interpret data related to four clients to determine how to delegate care responsibilities.

Knowledge
A nurse should explain to a client who has hypothyroidism that the purpose of levothyroxine (Synthroid) is to A. B. C. D. replace thyroid hormone. * stimulate the action of the thyroid gland provide thyroid-stimulating hormone. block the stimulation of the thyroid gland.

Comprehension
A nurse reviews medication precautions with a client who is taking levothyroxine (Synthroid). Which of these statements, if made by the client, would indicate that the client has the correct understanding of the instructions? A. I will take the medication every night at bedtime. B. I will be able to stop taking the medication when my symptoms improve. C. I will probably gain some weight while Im taking this medication. D. I will monitor my pulse rate while I am taking the medication. *
Requires understanding of precautions related to Synthroid to translate meaning of the clients statement

Requires memorization of the action of Synthroid. No understanding or judgment is required

Application
A client who is taking levothyroxine (Synthroid) telephones a home care nurse and says, I feel very anxious and I have been having palpitations. Which of these responses should the nurse make to the client? A. Do not take the medication and call your doctor.* B. That is an expected effect of the medicine. C. Make sure you change your position slowly. D. Cut back on your daily coffee intake.
Requires recognition of the adverse effects of Synthroid and also decision making skills to select the appropriate nursing intervention.

Analysis
A nurse is assessing a client who has been taking levothyroxine (Synthroid) for two weeks. The nurse identifies that the clients apical pulse rate is 82/min and the T3 and T4 serum levels have risen. The client reports having frequent urination and a weight loss of 3 pounds. Which of these actions should the nurse take? A. Administer the Synthroid and document the assessment findings. * B. Postpone giving the Synthroid and request a repeat of serum T3 and T4 C. Withhold the Synthroid and notify the physician of the assessment findings. D. Check the clients apical-radial pulse before giving the Synthroid.
Student must separate and prioritize information to identify relationship of data to safe medication administration. Requires understanding of the pathophysiology of hypothyroidism and the desired outcome of Synthroid

Analysis/Chart Interpretation
A nurse is assessing a client who has been taking levothyroxine (Synthroid) for two weeks. The nurse identifies the client data illustrated in the chart below:
4/10/10 Pulse Weight T3 T4 64 152 70 ng/dL 4 ug/dL 4/25/10 76 149 80 ng/dL 5 mcg/dL

NURSING PROCESS
Use the nursing process and Blooms taxonomy to frame the question Requires the question to be relevant to nursing practice Helps to eliminate trivial items at recall level Promotes item writing that assess higherorder thinking

Which of these actions should the nurse take? A. Administer the Synthroid and document the assessment findings. * B. Postpone giving the Synthroid and request a repeat of serum T3 and T4 C. Withhold the Synthroid and notify the physician of the assessment findings. D. Check the clients apical-radial pulse before giving the Synthroid.

Correct Answer
One and only one correct
Undeniably correct

Correct Answer Format

Which of these questions would be appropriate for a nurse to include when assessing a client for bulimia? A. How many times a day do you eat? B. Do you have any food allergies? C. What is your favorite snack food? D. Have you ever eaten in secret? *

Best Answer format

All options correct to a degree Referenced rationales

Best Answer/Priority Format

A nurse should give priority to which of these outcomes for a client who is experiencing a panic attack? A. The client will have decreased symptoms of anxiety. B. The client will avoid frightening situations. C. The client will learn thought-stopping techniques. D. The client will remain safe during the episode.*

Best Answer/Priority Format

Which of these clients is at highest risk for developing elevated serum potassium? A. A 34-year-old client who has renal failure * B. A 42-year-old client who has urinary retention C. A 65-year-old client who has hypertension D. An 82-year-old client who has hypothyroidism

Best Answer/Priority Format

A client who is hospitalized for treatment of exacerbation of chronic obstructive pulmonary disease (COPD) has all of these prescriptions. Which one should the nurse implement first? A. ciproflaxin (Cipro) 500 mg poq 12 hours B. methylprednisilone (Solu-Medrol) 100 mg IVPB q 4 hours C. albuterol (Proventil) 5 mg via nebulizer q 4 hours * D. quaifenesin (Robitussin) 200 mg q 4 hours

Best Answer/Priority Format

Which of these nursing actions is the priority when a client who has a fever of unknown origin is to be started on intravenous antibiotic therapy? A. Review the clients white blood cell count. B. Ensure that the clients blood culture is drawn. * C. Obtain the clients body temperature. D. Increase the clients oral fluid intake.

Delegating
Which of these tasks can a nurse assign to an unlicensed nursing assistant? A. Monitoring the pedal pulses of a 36-year-old client who had a femoral-popliteal bypass graft. B. Assessing the abdominal girth of a 56-year-old client who has cirrhosis C. Recording the Foley catheter output of a 68-year-old client who has pulmonary edema * D. Teaching a 72-year-old client who has emphysema to use an incentive spirometer

Recall

The mental status exam is a reflection of a clients

Nursing Process

Recall
A nurse should monitor a client who had a thyroidectomy six hours ago for signs of A. laryngeal nerve damage. * B. increasing intracranial pressure. C. carotid artery distension. D. hypercalcemia.

Which of these questions would be appropriate for a nurse to ask when conducting a mental status exam of a client?

Nursing Process
Which of these nursing measures should be carried out at regular intervals when caring for a client who had a thyroidectomy six-hours ago? A. Asking the client to speak. * B. Checking the clients pupillary response. C. Palpating the clients carotid arteries. D. Instructing the client to flex and extend the neck.

Recall
A client who has global aphasia will A. understand what is said but have difficulty verbalizing. B. respond normally to rote speech. C. exhibit dysfunction in both the areas of speech expression and reception.* D. verbalize clearly, but make no sense.

Nursing Process
Which of these actions should a nurse include when communicating with a client who has global aphasia? A. Give the client a pad and pen to write messages. B. Face the client and speak slowly in a loud voice. C. Have the family translate for the client. D. Demonstrate simple instructions to the client.*

Recall
A nurse is caring for a client post gastric resection with a nasogastric tube. The nurse knows that the client is at risk for
A. B. C. D. Hypernatremia. Hyperlkalemia. Metabolic alkalosis. * Hypoproteinemia.

Nursing Process
A nurse planning care for a client who had a gastric resection this morning and has a nasogastric tube (NGT) to continuous suction. Which of these measures should the nurse include in the clients care plan? A. Providing the client with ice chips. B. Adjusting the position of the NGT q 4 hours. C. Monitoring the clients serum pH. * D. Clamping the NGT when drainage becomes dark red.

Recall
The body organ from which the excretion of drugs and their metabolites primarily occurs is the A. Kidneys* B. Intestines C. Skin D. Lungs

Nursing Process
Which of these clients is at highest risk for inadequate excretion of ingested medications and their metabolites? A.A 32-year-old client who has liver failure. B.A 44-year-old client who has kidney failure.* C. A 54-year-old client who has intestinal obstruction. D. A 75-year-old who has benign prostatic hypertrophy.

Recall
Which of the following are NOT persons authorized to receive protected health information without the patients written authorization? A. Physician B. Public Health Department C. Family * D. Radiology Technician

Nursing Process
The wife of a hospitalized client says to a nurse, What were the results of my husbands laboratory tests? The client is awake, alert, and oriented. Which of these answers should the nurse offer? A. Ill get your husbands medical record and review the results with you. B. Your husband has to give written consent before I can share health information with you. C. Your husbands doctor is the only one who can discuss your husbands health information with you. .

Recall/Action in Stem
If at any time during hand washing the nurse suspects that he has contaminated his hands, he should begin again from the beginning of the procedure. A. true B. false

Actions in Options
A nurse suspects that the hands have been contaminated during hand washing. Which of these actions should the nurse take? A. Rinse the hands for an extra thirty seconds B. Put on gloves before providing client care C. Start again from the beginning of the procedure. * D. Increase the temperature of the water

Multiple Response
A nurse is planning care for a patient who had a right hip replacement three days ago. Which of these actions should the nurse include? Select all that apply. A. Instructing the patient not to cross the legs B. Keeping the patient on strict bed rest C. Advising the patient to use a raised toilet seat D. Teaching the patient to bend at the waist when picking up items from the floor E. Explaining that the patient will have to use an abduction pillow for life

Answer: A C

Conclusion
Clarity is essential Style guide increases clarity Creativity is important Items must require thinking Avoid recall Test ONLY important concepts Clearly state the problem in the stem Keep the actions in the options Make sure the items are clinically relevant Use the nursing process as a framework

Questions???