Student Assessment: Multiple Choice Questions







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What is MCQ?

Advantage and limitations of MCQ

• Structure of MCQ

• Rules and Guidelines of MCQ item construction

• Common flaws in MCQ item construction


Multiple choice (objective response) is a form of an

objective assessment in which respondents are asked to select only correct answers from the choices offered as a list.


• Quick and easy to score, manually or electronically

• Appropriately constructed MCQs can measure higher order thinking

Easier to control the difficultly level


Time consuming to construct good MCQ items

Need skill to construct good MCQ

Often test knowledge


Structure of a multiple choice question consists of:

The stem

The lead-in



The stem presents the stimulus or information needed to answer the question

Good stems are written in the form of vignette (illustration), including


• Gender

Presenting complaint Pertinent history

• Physical examination findings

Results of diagnostic and laboratory studies


Example of a stem:

A 24 year old woman came to a hospital with a complaint of sudden onset of lower crampy abdominal pain


The lead-in presents the specific question that defines the task and establishes the relationship between the stem and options


The option set ,the choices provided after the stem; It includes:

• The key- the correct answer in the list of options

• Distracters -the incorrect answers in the list of options


Make sure that MCQs relate directly to learning outcomes; and are at different levels of learning

(recall, comprehension, application and problem solving, etc.)

Use vignettes to structure the stem

Be aware of the difficulty level of each question


• Make sure you have a sufficient number of easy and more challenging questions

Try to make the first few multiple choice questions relatively easy to help calm student



• Provide a complete statement

• Include only relevant information • Put central idea in the stem

• Keep stems as short as possible

• Ask for the correct, not “wrong” answer



• Have only one correct answer

• Consider the number of distracters

• Avoid long options

• Keep options similar length

• Keep options grammatically consistent with the stem

• Write the correct response with no irrelevant clues



Write incorrect options to be probable but clearly incorrect

Link options to each other (e.g., all diagnoses, treatments)

Write distracters to be similar to the correct answer in terms of grammar, length, and complexity

Avoid “none of the above” or “all of the above”



Place options in logical order (e.g. numerical, chronological)

Avoid items like: A only, A+B

Write options to be not overlapping

Vary position of keyed responses



• Avoid absolute terms such as “always”, “never”, “all”, or “none”

• Avoid imprecise terms such as “seldom”, “rarely”, “occasionally”, “sometimes”, “few”, or “many”


An asymptomatic 57-year-old man comes to the physician for a routine health maintenance examination. His blood pressure is 180/112 mm Hg, and pulse is 82/min. Abdominal examination shows a bruit in the right upper quadrant and no masses. The most likely cause of this patient’s bruit is an:

A) accumulation of lipids in the arterial wall B) hypertrophy of the arterial wall media C) giant cell infiltration in the arterial wall D) round cell infiltration in the arterial wall


Crime is

a. Equally distributed among the social classes

b. Overrepresented among the poor

c. Overrepresented among the middle class and rich

d. Primarily an indication of psychosexual maladjustment

e. Reaching a plateau of tolerability for the nation


Which of the following statements is the most accurate about croup in children?

a. Can be treated adequately with oral dexamethasone b. Could be a complication of hypercalcaemia

c. Is never seen in patients under 3 months d. Is rarely fatal 

e. Possibly relates to immaturity of cartilaginous development


A 67-year-old woman is brought to the emergency department because of severe chest pain four hours after undergoing outpatient endoscopy and dilatation of an oesophageal stricture caused by reflux.

Which of the following is the most likely cause of these symptoms?


Which of the following best describes the commonest organism causing bacterial pneumonia in childhood? a. Gram positive coccus, occurring in chains

b. Gram positive coccus, occurring in pairs c. Gram negative coccus, occurring in pairs d. Gram negative coccus, occurring in chains e. Gram positive bacillus, occurring in pairs


Inconsistent proportions or units

What is the incidence of hospital admission due you to post abortion complication?

a. 1% b. 3% c. 5% d. 15%


• Divide into groups

• Construct five multiple choice questions; three

correctly constructed and two containing common errors

• Present to the large group for discussion


• A tool for new item writers

• Can develop new items, using shells constructed from items with good track records


A (patient description) has (history findings) and is

taking (medications). Which of the following medications is the most likely cause of his (one history, PE or lab



A (patient description) has (abnormal findings). Which [additional] finding would suggest/suggests a diagnosis of (disease 1) rather than (disease 2)?


A (patient description) has (symptoms and signs). These observations suggest that the disease is a result of the (absence or presence) of which of the following

(enzymes, mechanisms)?


A (patient description) has (symptoms, signs, or specific disease) and is being treated with (drug or drug class). The drug acts by inhibiting which of the following

(functions, processes)?


Design new items from existing items by altering:

Setting (Hospital or Clinic)

Level of Clinical Decision Making Process

(Data Collection or Planning)


Used to assess

• Critical thinking

• Problem-solving • Decision- making


A 24 years old female has been receiving care in your health center since learning that she was HIV positive three years ago.

• Never started on ART

• Frequent episodes of generalized body weakness

Recurrent vaginal candidiasis which failed to respond to clotrimazole suppositories on two occasions


Question 1:

Which of the following WHO stage is this patient in based on the available clinical information

A. Stage I B. Stage II C. Stage III D. Stage IV


Question 2:

Which of the following laboratory tests would be MOST important prior to initiating ART?

A. Total lymphocyte count B. CD4 cell count

C. Viral load

D. KOH test and/or wet smear for diagnosis of candidiasis


• Divide in to groups

• Develop three multiple choice items each that measuring knowledge , application and analysis /evaluation (clinical decision making) skills

• Write down items on to computer and present to large group for discussion

• Time: 20 min