Running head: CRITIQUE OF TEST QUESTIONS 1

Critique of Test Questions

Kristen Eden

Bethel College
CRITIQUE OF TEST QUESTIONS 2

Critique of Test Questions

Testing by examination is one of the most effective ways to evaluate student learning. A

well-constructed exam will assess the student’s understanding at a variety of cognitive levels

ranging from knowledge and comprehension to application and analysis (McDonald, 2018).

Examinations are often used to provide summative evaluation of the student’s comprehension of

the material. Therefore, the exam must be written in a clear and organized manner (Billings &

Halstead, 2016).

This paper will analyze 10 test items for clarity, accuracy of information, and overall

organization to determine if the items are appropriate to evaluate student learning. Each stem and

option will be assessed for accuracy of information and quality of organization. The questions

will then be revised to show how each might be improved.

Original question 1:

1. The head-to-tail direction of growth is referred to as which of the following:

a. cephalocaudal
b. proximodistal
c. mass to specific
d. sequential

This test question is written at the knowledge level. It simply requires the student to recall

that the head-to-tail direction of growth is cephalocaudal, which is the very definition of the

term. Though this is an important fact to know when assessing the development of a child, the

question does not require the student to delve deeper in their understanding of the term. This test

question does stand on its own. The stem does not contain any clues. There are no spelling errors

but the options should each be capitalized. Each of the four options are plausible, as they all

relate to growth and development.

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The question is written succinctly, however the stem is written in a completion format.

The completion stem format is controversial because it increases the cognitive complexity of the

question, forcing students to read the question multiple times and inevitably form the stem into a

question (McDonald, 2018). The options are listed correctly. The words nurse/and or client are

not used in the stem. The stem does provide all necessary information to answer the question, as

it is simply asking the definition of the correct option. A negative stem was avoided.

The options do not overlap, as they each have separate definitions and only one is correct.

The distractors are completely incorrect but plausible as they are all types of growth. Each of the

options are grammatically correct and consistent with the stem.

Improved question 1:

The nurse is assessing the client for appropriate growth and development. What term
would the nurse use to describe the head-to-tail direction of growth?

A. Cephalocaudal
B. Proximodistal
C. Mass-to-specific
D. Sequential

The question is improved by creating a scenario with a nurse and client. The stem is

reworded to form a question. And each of the options is capitalized.

Original Question 2:

2. When taking the pulse of a 4- year- old child, for most accuracy, it should be taken for:

a. 30 seconds and double the number.

b. 60 seconds.
c. 15 seconds and quadruple the number.
d. any of the above are acceptable.

This question is written at the comprehension level. The student must simply understand the

best method for obtaining the pulse of a four-year old child. The question is succinct but wordy
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and it is written as a completion statement. The spelling is correct but the hyphenation of “4-

year-old” is grammatically incorrect as there are too many spaces inserted. When reading the

stem with each option, options A-C could form a complete sentence, but option D is awkward as

it could not be read as the ending to the stem if it were a full sentence. In this case it is not

uniform. The question does stand on its own and there are no clues in the stem. This question is

appropriate at the knowledge/comprehension level.

The stem of this question does not contain the words nurse or patient, but the question

addresses a four-year-old child as the subject. The stem does provide all the necessary

information to answer the question. It is simply asking how to accurately take the pulse of a

child. The stem does not contain any extraneous information. A negative stem was avoided in

this question.

The answers options could overlap, as answer D asks if the answers are all correct ways to

measure the pulse. There is only one correct answer to this question, as option C is the preferred

method of obtaining a four-year-old’s pulse. The distractors are all appropriate but most students

would immediately rule out option D, as they are aware the question assumes there is a correct

method of obtaining the pulse of a four-year-old.

Improved question 2:

The nurse is obtaining the pulse of a 4-year-old client. The most accurate method of
obtaining the pulse is to check for:

A. 30 seconds and multiply by two

B. 60 seconds
C. 15 seconds and multiply by four
D. 20 seconds and multiply by five

Question 2 has been improved by rewording the stem for clarity and conciseness. In this

situation, the stem was kept in the completion format and the options were reworded for
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consistency. Punctuation was corrected and the option “any of the above are acceptable” was

replaced.

Original Question 3:

3. The nurse is admitting a 15- year- old to the Pediatric unit. What is the primary
developmental task for this age group:
a. intimacy
b. identity
c. industry
d. initiative

This question is written at the knowledge level. It is succinctly worded, stands on its own,

and is clear in what it is asking. However, this question has multiple errors in grammar and

punctuation. It is also worded as a question but does not have a question mark in the stem.

The word nurse is included but the word client or patient is not. The stem refers to a 15-

year-old. All necessary information is included in the stem, as it is simply asking what the

primary developmental task for a 15-year-old is. The stem is clear and the student must simply

answer with the correct option. There is only one correct option, which is option B. A negative

stem was avoided.

The options in this question do not overlap, as they are all distinct stages of development.

There is only one correct answer, option B, but options A-C are plausible. Each option is

consistent with the stem and grammatically correct.

Improved question 3:

The nurse is admitting a 15-year-old client to the pediatric unit. According to Erickson,
what is the primary developmental task for this client?

A. Intimacy
B. Identity
C. Industry
D. Initiative
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This question has been improved by rewording the stem into a question. Punctuation and

capitalization has been improved. The student must now choose what developmental task a 15-

year-old might appropriately struggle with.

Original question 4:

4. Which of the following vital signs indicates that a 5 year old child requires immediate
attention:
a. Systolic blood pressure of 80 mmHg
b. Diastolic blood pressure of 60 mm Hg
c. Pulse of 94 beats per minute.
d. Respiratory rate 62 breaths per minute.

This question is written at the analysis level. It requires the student to know the normal

vital sign measurements of a 5-year-old and recognize which finding requires immediate

attention. The question is succinctly worded and stands on its own. The stem does not contain

any clues. The question is clear but there are grammatical and punctuation errors present. This

question is written at an analysis level and is appropriate for students.

The words nurse and/or client are not present. The stem does not contain all necessary

information because it does not state whether the child is resting or active. But it does provide

the child’s age and asks which of the four options is out of range and requiring intervention. The

stem is clear but written as a question without proper punctuation. Option D is the only one that

requires immediate attention as options B and C are within normal range. Option A is at the

beginning hypotensive range, but option D is twice the normal respiratory rate indicating

respiratory distress. In this question, a negative stem was avoided.

None of the options in this question overlap as they are all distinct vital sign

measurements. There is only one correct option, though students might see option A as out of

range and choose this option. However, the student must remember that the nursing priority is
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breathing before circulation. The options are grammatically correct besides option D which

omitted the word “of” before 62.

Improved question 4:

The nurse enters the room of her 5-year-old patient to obtain vital signs and finds him
lying in bed with signs of distress. Which of the following vital signs requires immediate
attention?

A. Systolic blood pressure of 80 mmHg

B. Diastolic blood pressure of 60 mmHg
C. Pulse of 90 beats per minute
D. Respiratory rate of 62 breaths per minute

Question four has been improved by creating the stem into a question format and creating

a situation that the student can visualize and respond to. The qualifier of resting is added to assist

the student in deciding if the vital signs are within range or not. Capitalization errors have also

been corrected.

Original question 5:

5. The nurse should suspect a hearing impairment in an infant who demonstrates which of
the following behaviors? SELECT ALL THAT APPLY:
a. Absence of the rooting reflex
b. Absence of babbling by age 7 months.
c. Lack of response when being spoken to.
d. Absence of startle reflex

This question is written at the analysis level. The student must remember the signs of

hearing impairment in an infant and look at the options to assess which would indicate

impairment in hearing. This question is succinctly worded and does not contain any clues for the

student. Spelling is correct but there are errors in punctuation and spacing of words.

The word nurse is included and it may be assumed that the infant is the patient. The stem

provides all necessary information. It includes the impairment to be assessed and the age of the

client. A negative stem was avoided in this question.

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None of the answer overlap as each is a different type of response. Since this is a select-

all-that-apply format, there will be more than one correct option but there are clearly options that

do not indicate hearing impairment, such as option A. The distractors are plausible if the student

is unaware of what the rooting reflex is. Option C is not grammatically consistent with the rest of

the options. Also, when writing select all that apply questions, there must be between five and

nine options (McDonald, 2018).

Improved question 5:

Which behaviors should cause the nurse to suspect hearing loss in an infant? Select all
that apply.

A. Absence of rooting reflex

B. Absence of babbling by age of 7 months
C. Absence of response when being spoken to
D. Absence of startle reflex
E. Absence of Babinski reflex

Question five has been improved by creating the stem into a question. “Select all that

apply” is no longer unnecessarily capitalized and bolded. The options are all changed for

uniformity and a fifth option is added to comply with the required number of options for a select-

all-that-apply question format.

Original question 6:

6. A 6-year-old boy comes into the clinic to receive his immunizations for Kindergarten.
The nurse will administer which of the following immunizations, assuming he is up to
date on his shots? SELECT ALL THAT APPLY:
a. DTaP ( Diptheria, Tetnus, acellular Pertussis)
b. Hib ( Haemophilus influenzae type b)
c. MMR ( Measles, Mumps, & Rubella)
d. IPV ( Inactivated Polio)
e. PCV (Pneumococcal)

This question is written at the knowledge level. The student must know the normal

vaccine schedule for children and choose which of the vaccines are appropriate to administer to a
CRITIQUE OF TEST QUESTIONS 9

child who is up to date on their vaccinations. The question is succinct and stands on its own. The

stem does not contain any clues and is clearly asking what immunizations should be

administered to the child. The question contains spelling, grammar, and punctuation errors.

The stem does contain the word nurse but should refer to the 6-year-old as the patient or

client. The stem provides all the necessary information for the student to answer the question. It

gives the age of the patient and asks what immunizations are appropriate for the nurse to

administer. A negative stem was avoided.

The options in this question do not overlap. All options are different immunizations with

appropriate administration guidelines. Since this is a multiple choice format, there will be some

correct answers and some incorrect answers, but there should not be any ambiguity when

deciding what is appropriate at this time. The distractors are all plausible since they are all

vaccinations that must be given at different ages. All options are grammatically correct. The

student must determine that the child is due for options A, C, and D.

Improved question 6:

The nurse is preparing to administer vaccinations to her six-year-old patient. He is

currently up-to-date on his prior vaccinations and will be soon attending kindergarten.
Which of the following vaccines should the nurse administer at this time? Select all that
apply.

A. DTaP (Diptheria, tetanus, & acellular pertussis)

B. Hib (Haemophilus influenza type b)
C. MMR (Measles, mumps, rubella)
D. IPV (Inactivated poliovirus)
E. PCV (Pneumococcal)

The wording of this question has been improved. The options have been capitalized and

spacing errors have been fixed. The student can now make a decision about which vaccinations

are appropriate for the child entering kindergarten.

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Original question 7:

7. The nurse is evaluating the developmental level of a 2-year-old. Which of the following
does the nurse expect to observe in this child?

a. Walks up & down stairs

b. Turns door knobs
c. Puts two words together
d. All the above

This question is an application question as it requires the student to understand the stages

of development and appropriate actions for a two-year-old and assess which actions are

expected. The question is succinctly worded and stands on its own with no clues included. The

question clearly asks what actions a nurse should expect to observe in a two-year old. There are

no spelling or grammatical errors but the stem is grammatically inconsistent with the options.

The word nurse is included but the two-year-old should be referred to as the client or

patient. The stem does provide all the necessary information, as it provides the age of the child

and asks the student to identify the developmentally appropriate actions for this child. However,

the question is not in a select-all-that-apply format so there should only be one correct option.

Option A is tricky because a two-year old should be able to walk up and down stairs while

holding on, but be unable to walk up and down stairs with one foot on each step until age three.

Option A does not specify and may confuse the student. Option C is also correct. The test-wise

student will realize that only one option may be correct in a multiple-choice question, so option

D should be discarded.

Improved question 7:

The nurse is evaluating the developmental level of a two-year-old patient. The nurse
determines that this child has achieved the appropriate developmental milestones when
the child

A. Walks up and down stair while holding onto the railing.

B. Takes turns while playing games.
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C. Catches a bounced ball most of the time.

D. Separates easily from mom and dad.

This question has been improved by forming the stem into a completion format so that

there is grammatical consistency with the options. There is now only one correct option, as

option A is the only milestone a two-year-old should be able to complete. Capitalization and

punctuation errors have been fixed.

Original Question 8:

8. An infant who weighs 7 pounds at birth would be expected to weigh how much at
1 year of age?
a. 14
b. 16
c. 18
d. 21

This question is written at the comprehension level. The student should remember the normal

weight gain of an infant. Babies are expected to double their weight by six months and triple

their weight by one year of age. The student must simply remember this normal growth rate and

multiple the original weight by three.

The question is succinctly worded and stands on its own. The stem does not contain any

clues and spelling is correct. The question clearly asks how much the baby should weigh at one

year of age.

The words nurse and client are not included in the stem. The stem does provide all

necessary information, because a normal growth rate is known and we have the current weight of

the infant. There is only one correct answer to this question, as option D is the only option that is

triple the infant’s weight. A negative stem was avoided in this question. The distractors are

completely incorrect, yet plausible. And the options are grammatically consistent with the stem.
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Improved question 8:

An infant who weighs seven pounds at birth would be expected to weight how much at
one year of age?

A. 14 lbs.
B. 16 lbs.
C. 18 lbs.
D. 21 lbs.

This question does not require much improvement. The option letters have been

capitalized and the unit of measurement has been added to the options. Each of the options is

plausible but there is only one correct answer (D.).

Original question 9:

9. The developmental task with which the child of 15 to 30 months is likely to be struggling
is sense of what?
a. Trust
b. Initiative
c. Autonomy
d. Intimacy

This question is written at the knowledge level. It is asking the student to identify the

stage of development the 15 to 30 month is in (toddler stage) and what psychosocial

developmental task a toddler would be struggling with. The question is succinct but the stem is

written in a choppy manner. The question does stand on its own and there are no clues in the

stem.

The words nurse and client/patient are not included in the stem. The stem does contain

the necessary information for the student to decide which task the toddler will be struggling with.

There is only one correct answer, which is B. The other three options are also psychosocial

development tasks so they are plausible but completely incorrect in this situation. The options

are all grammatically correct and consistent with the stem.

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Improved question 9:

The nurse is assessing the psychosocial development of a toddler client. What

psychosocial task should the nurse recognize this client may be struggling with?

A. Trust
B. Initiative
C. Autonomy
D. Intimacy

The stem was reworded and is more clear. The student must determine what task a

toddler struggles with. The stem in this question needed to be reworded for clarity.

Original question 10:

10. A 7-year-old presents to the office with Rheumatic fever. You suspect the child had?
e. Rocky Mountain Spotted fever
f. Strep throat
g. A virus
h. Mononucleosis

This question is written at the application level. The student must determine what type of

infection from the list of options could have caused the rheumatic fever. They must be familiar

with rheumatic fever and know what type of infection precedes this condition. The question is

succinctly worded and stands on its own. The stem does not contain any clues but the words “in

the past two weeks” might be a giveaway to some students as the option is not uniform with the

others. The punctuation needs improvement and the grammar is incorrect.

The words nurse and client/patient are not included in the question. The stem contains all

the information necessary for the student to answer the question. And there is only one answer,

which is option F. Since this question is standing alone, the options should be lettered A-D.

The answer options do not overlap and there is only one correct answer. The distractors

are completely incorrect and plausible, yet the options are not as uniform as should be expected.
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Option F is a bacterium, G is simply listed as a virus, E is a condition caused by the bacteria

Rickettsia rickettsia, and H is an infection caused by the Epstein-Barr virus.

Improved question 10:

The nurse is caring for a seven-year-old patient with rheumatic fever. Which infectious
agent might the patient have previously been infected with?

A. Rickettsia rickettsia
B. Streptococcus pyrogenes
C. Influenza virus
D. Epstein-Barr virus

The question was reworded for clarify and grammatical consistency. The options were

changed so that the original infectious agents are listed. The option letters have also been

changed to not confuse the student who might think the options are part of a different question.

In conclusion, test item writing is a complicated art and science that must be taken

seriously in order to evaluate the effectiveness of a student’s learning. Using correct formats and

clarity of language is important because confusing and inconsistent language will frustrate the

student and impair their ability to demonstrate their knowledge and understanding of the

material. Nurse educators must ensure they are complying with test item writing standards when

writing their exams to ensure the best outcomes will be met by their students.
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References

Billings, D. & Halstead, J. (2016). Teaching in nursing (5th ed.). St. Louis, MO: Elsevier.

McDonald, M. (2018). The nurse educator’s guide to assessing learning outcomes. Burlington,

MA: Jones & Bartlett Learning.