Have you ever watched a room full of students taking a multiple choice exam? I have, many times. I have watched students as they grumble, look up at the ceiling, groan, and squirm in their seats. I have even seen some cry. Multiple choice (MC) questions – student hate them and faculty are not comfortable writing them. Students thought my questions were too difficult, vague, or confusing. Of course, I felt differently about those multiple choice questions. I thought the questions were clear, concise, and fairly met every objective I asked the students to know. What could have possibly gone wrong? How did the students and I have such different opinions regarding those exam questions? It was probably because the questions were not written as well as they could have been. I had a lot to learn about writing MC exam questions.

Many faculty have little or no training in writing exam questions, yet are expected to assess students in courses using MC questions. Multiple choice question writing requires time, patience, and experience. It is also more difficult than it appears to write really good MC questions. In this Toolbox, I would like to review some tips on writing MC exam questions.

Though developing well-written MC questions can be difficult, MC questions are very useful, such as in assessing student knowledge in large classes where grading individual exams can be time-consuming. Additionally, as long as students do not receive a copy of the exam, questions can be placed in a test bank to be used again. They are easily written to assess lower level thinking skills such as knowledge or comprehension. Higher thinking skills, such as application, synthesis, and evaluation can be assessed; however, it is just more difficult to write such questions. If students have a limited time in which to complete an exam, allow approximately one minute per MC question. All questions should be mapped back to the course objectives. Additionally, all lecture or course objectives should be tested, otherwise, why have them?

Despite some of the limitations, MC questions are easy to grade (can be computer graded), can avoid the guessing factor of true/false questions, and are reliable and versatile.

Be sure to give yourself plenty of time to write the questions, review them, and perhaps have someone you work with review them or even take the exam. With some practice, you will be on your way to writing better multiple choice exam questions!

Examples of poorly written questions are provided to illustrate the problems you should attempt to avoid.

  1. 1. Parts of the MC question:

    • Stem – presents the problem and has a verb in it. Use cases when possible.

    • Distractors – a list of the answer choices.

  2. Should have the same number of answers throughout an exam to avoid confusion. Three or four possible answers are reasonable. There should never be more than 5 answers.

  3. Write the correct answer before the distractors. This way, your focus will be on formulating one, clear correct answer.

  4. Be simple, direct, and concise – do not put a lot of unnecessary information in the question.

  5. All options should be plausible – do not put impossible answers in. Use words familiar to students.

  6. Answers should be grammatically correct. Students will know if an answer needs to begin with a vowel or consonant. E.g.: The correlation coefficient found by correlating students' scores on a classroom math test with their scores on a standardized math test is called

    • validity coefficient

    • index of reliability

    • equivalence coefficient

    • internal consistency coefficient

  7. Alphabetize options, when appropriate. E.g.: Which of the following is the best initial treatment and dose for panic disorder?

    • sertraline 25 mg once daily

    • fluoxetine 40 mg once daily

    • clomipramine 75 mg twice daily

    • paroxetine 40 mg once daily

  8. Numbers and letters in answers are in numerical or alphabetical order. E.g.: If the answers are vitamins A, B, C, D, place them in order

  9. All answers should be similar in length.

  10. Avoid ambiguity – do not use “usually”, “often”, or “rarely”. Likewise, avoid extreme words like “all”, “always”, and “never”.

  11. Avoid the use of negatives in the stem. E.g.: Which of the following is NOT a routinely recommended antihypertensive medication in a stroke patient who is a potential candidate for tPA?

  12. Avoid repeating words in the answer. Alternatively, you may include repeated words in the stem. E.g.: Why is it necessary to increase the dose of lamotrigine slowly? (This question is also an example for number 9 above – the clue to the correct answer is that it is longer than the others.)

    • it causes dose-related psychomotor slowing

    • it causes renal stones

    • it causes dose-related paresthesias

    • it causes a dose-related rash that can be potentially life threatening.

  13. Spell out abbreviations!

  14. Avoid regional biases or slang in questions. Ensure the questions are appropriate for diverse populations of students.

  15. Answers should be independent and mutually exclusive – NO OVERLAP IN ANSWERS. E.g.: Which of the following indicates severe depression on the Hamilton Depression Rating Scale (HAM-D)?

    • 7–12

    • 12–18

    • 18–24

    • 22–28

  16. Do not teach in the exam question. E.g.: Which of the following is true?

    • Patients with DM and CKD no longer have to limit carbohydrate intake because damaged kidneys dispose of excess glucose in the urine therefore reducing blood glucose values.

    • The use of fiber supplements in diabetic patients with CKD is discouraged due to the increased need for fluid intake and its effect on blood pressure.

    • Fluid restriction is typically not required until CKD Stage 5.

    • Eggs are an inexpensive and excellent source of biological value protein while also helping to achieve appropriate amounts of dietary cholesterol for hormone synthesis.

  17. The problem should be described in the stem, not in the answers. E.g.: World War II was:

    • The result of the failure of the League of Nations.

    • Horrible.

    • Fought in Europe, Asia, and Africa.

    • Fought during the period of 1939–1945.

  18. Avoid the use of “none of the above” and “all of the above”.

    • These answer choices promote guessing. If two answers are correct or incorrect, then “all or none” is the correct answer. You will not know what the student really knows.

  19. There should be no pattern for the correct answers. Students will figure out the pattern quickly!

Testing: The details
McKeachie's Teaching Tips
Boston, MA
National Board of Medical Examiners
Constructing written test questions for the basic and clinical sciences
; 3rd edition.
Philadelphia, PA