case study multiple choice questions

• Research article
• Open access
• Published: 02 February 2016

Case-based learning and multiple choice questioning methods favored by students

• Magalie Chéron 1 ,
• Mirlinda Ademi 2 ,
• Felix Kraft 3 &
• Henriette Löffler-Stastka 1  

BMC Medical Education volume  16 , Article number:  41 ( 2016 ) Cite this article

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Investigating and understanding how students learn on their own is essential to effective teaching, but studies are rarely conducted in this context. A major aim within medical education is to foster procedural knowledge. It is known that case-based questioning exercises drive the learning process, but the way students deal with these exercises is explored little.

This study examined how medical students deal with case-based questioning by evaluating 426 case-related questions created by 79 fourth-year medical students. The subjects covered by the questions, the level of the questions (equivalent to United States Medical Licensing Examination Steps 1 and 2), and the proportion of positively and negatively formulated questions were examined, as well as the number of right and wrong answer choices, in correlation to the formulation of the question.

The evaluated case-based questions’ level matched the United States Medical Licensing Examination Step 1 level. The students were more confident with items aiming on diagnosis, did not reject negatively formulated questions and tended to prefer handling with right content, while keeping wrong content to a minimum.

These results should be taken into consideration for the formulation of case-based questioning exercises in the future and encourage the development of bedside teaching in order to foster the acquisition of associative and procedural knowledge, especially clinical reasoning and therapy-oriented thinking.

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Trying to understand how students learn on their own, aside from lectures, is essential to effective teaching. It is known that assessment and case-based questioning drive the learning process. Studies have shown that the way assessment is being conducted influences students’ approach to learning critically [ 1 ]. Several written methods are used for the assessment of medical competence: Multiple Choice Questions (MCQs), Key Feature Questions, Short Answer Questions, Essay Questions and Modified Essay Questions [ 2 ]. Based upon their structure and quality, examination questions can be subdivided into (1) open-ended or multiple choice and (2) context rich or context poor ones [ 3 , 4 ].

Well-formulated MCQs assess cognitive, affective and psychomotoric domains and are preferred over other methods because they ensure objective assessment, minimal effect of the examiner’s bias, comparability and cover a wide range of subjects [ 5 ]. Context rich MCQs encourage complex cognitive clinical thinking, while context poor or context free questions mainly test declarative knowledge (facts, “what” information), which involves pure recall of isolated pieces of information such as definitions or terminologies. In contrast, procedural knowledge (“why” and “how” information) requires different skills: Students are encouraged to understand concepts and to gather information from various disciplines in order to apply their knowledge in a clinically-oriented context. Remarkably, prior clinical experience has been suggested to be a strong factor influencing students’ performance in procedural knowledge tasks [ 6 , 7 ]. With the focus of teaching students to think critically, test items must require students to use a high level of cognitive processing [ 3 ]. A successful approach is using Extended Matching Items (EMIs), consisting of clinical vignettes [ 2 ]. This format is characteristic for examination questions in Step 2 of the United States Medical Licensing Examination (USMLE) [ 8 ]. Step 2 items, test the application of clinical knowledge required by a general physician and encourage examinees to make clinical decision rather than to simply recall isolated facts [ 6 ]. As a well-established examination format introduced by the National Board of Medical Examiners (NBME) USMLE question criteria served for the comparison in our study.

Case-based learning (CBL) has gained in importance within past years. This well-established pedagogical method has been used by the Harvard Business School since 1920 [ 9 ]. Nevertheless, there is no international consensus on its definition. CBL as introduced to students of the Medical University of Vienna (MUV, Austria) in Block 20 is inquiry-based learning demanding students to develop clinical reasoning by solving authentic clinical cases presented as context rich MCQs. Generally, exposing students to complex clinical cases promotes (1) self-directed learning, (2) clinical reasoning, (3) clinical problem-solving and (4) decision making [ 9 ]. In contrast to other testing formats CBL facilitates deeper conceptual understanding. As students see the direct relevance of the information to be learnt, their motivation increases and they are more likely to remember facts. Studies showed that CBL fosters more active and collaborative learners and that students enjoy CBL as a teaching method [ 9 ]. This is in line with the improving results from the students’ evaluation of the course Psychic Functions in Health and Illness and Medical Communication Skills-C ( Block 20/ÄGF-C ) performed in 2013 [ 10 ] and 2014 [ 11 ] at the MUV. A Likert scale ranging from 1 (very bad) to 4 (very good) was used to evaluate the quality of the lectures: The mean grade improved from 1.6 in 2013 to 3 one year later, after the introduction of online case-based exercises related to the lectures. Therefore, based upon the assumption that students tend to prefer practical learning, the development of case-based question driven blended-learning will be further encouraged at the MUV, in order to aim for an effective training for the fostering of procedural knowledge, necessary for clinical reasoning processes and clinical authentic care.

There are no published studies analyzing the way medical students construct MCQs regarding their level of clinical reasoning. To learn more about how students deal with case-based questioning we analyzed student-generated MCQs. The study gives important insights by examining students’ way of reasoning, from formal reasoning using only declarative knowledge to clinical and procedural reasoning based on patients’ cases. Moreover, this study allows to observe to what extent negatively formulated questions, a rarely used format in exams, may not be a problem for students.

This analysis is based on the evaluation of a compensatory exercise for missed seminars completed by students in their fourth year of medical studies at the MUV, after attending their first course on psychic functioning ( Block 20/ÄGF-C ). The 5-week-long Block 20 [ 12 ] focused on the fundamentals of psychic functions, the presentation of the most important psychological schools and on the significance of genetic, biological, gender-related and social factors, as well as on the presentation of psychotherapeutic options and prevention of psychic burden [ 13 ]. Basis of the doctor-patient communication and of psychological exploration techniques were offered [ 12 ]. To pass Block 20 , all students had to take part to the related online CBL [ 14 ] exercise. This exercise presented patients cases including detailed information on diagnosis and therapy, subdivided in psychotherapy and pharmacology. The students had to answer MCQ concerning each diagnostic and therapeutic step.

The current study was approved by the ethics committee of the Medical University of Vienna, students gave informed consent to take part and data is deposited in publicly available repositories (online CBL exercise) after finishing the study. The students were instructed to create MCQs with 4–5 answer possibilities per question, related to cases of patients with psychopathological disorders presented in the online CBL exercise and in the lectures’ textbook of the Block 20 [ 15 ]. The “One-Best Answer” format was recommended. Additionally, the students were required to explain why the answers were right or wrong. MCQ examples were offered to the students in the online CBL exercise.

The authors performed the assessment and classification of the students’ MCQs after group briefings. A final review was done by MC to ensure inter-rater reliability, it was stable at k  = .73 between MC and HLS.

Subjects covered by the questions

The proportions of epidemiology, etiology/pathogenesis, diagnosis and therapy oriented items were examined. In order to simplify the classification, etiology and pathogenesis items were gathered into one group. Items asking for symptoms, classifications (e.g. ICD 10 criteria) as well as necessary questions in the anamnesis were gathered as diagnosis items. Among the therapy items, the frequency of items concerning psychotherapy methods and pharmacology was also compared. The proportion of exercises including at least one diagnosis item and one therapy item was observed. These subjects were chosen according to the patient cases of the CBL exercises and the lectures’ textbook.

Level of the questions

The level of the questions was evaluated in comparison to USMLE equivalent Steps 1 and 2, as described by the NBME. While Step 1 questions (called recall items ) test basic science knowledge, “every item on Step 2 provides a patient vignette” and tests higher skills. Step 2 questions are necessarily application of knowledge items and require interpretation from the student [ 6 ].

To assess the level of the items, 2 further groups were created, distinguishing items from the others. Examples of Step 1 and Step 2 Items’ stems offered by the students:

Step 1: “What is the pharmacological first line therapy of borderline patients?” (Item 31) Step 2: “M. Schlüssel presents himself with several medical reports from 5 specialists for neurology, orthopedics, trauma surgery, neuroradiology and anesthesia, as well as from 4 different general practitioners. Diagnostic findings showed no evidence for any pathology. Which therapy options could help the patient?” (Item 86)

Further, “Elaborate Items” were defined by the authors as well thought-out questions with detailed answer possibilities and/or extensive explanations of the answers.

Finally, “One-Step questions” and “n-steps questions” were differentiated. This categorization reflects the number of cognitive processes needed to answer a question and estimates the complexity of association of a MCQ. Recall items are necessarily one-step questions, whereas application of knowledge items may be one-step questions or multiple (n) steps questions. Because the evaluation of the cognitive processes is dependent on the knowledge of the examinee, the NBME does not give priority to this categorization anymore, although it gives information on the level and quality of the questions [ 6 ]. The previous example of a Step 2 question (Item 86) is an application of knowledge (Step 2) item categorized as n-Step item, because answering the question necessitates an association to the diagnosis, which is not explicitly given by the question. An example for a Step 2 question necessitating only one cognitive process would be: “A patient complains about tremor and excessive sweating. Which anamnestic questions are necessary to ask to diagnose an alcohol withdrawal syndrome?” (Item 232)

Formulation of the questions

The proportion of positively and negatively formulated questions created by the students was examined, as well as the number of right and wrong answer choices, in correlation to the formulation of the question.

Descriptive statistics were performed using SPSS 22.0 to analyze the subjects covered by the questions, their level and formulation, and the number of answer possibilities offered. The significance of the differences was performed using the Chi-square Test or Mann–Whitney U Test, depending on the examined variable, after testing for normal distribution. A given p -value < .05 was considered statistically significant in all calculations.

The study included 105 compensation exercises, performed by 79 students, representing 428 MCQs. After reviewing by the examiner (HLS), who is responsible for pass/fail decisions on the completion and graduation concerning the curriculum element Block 20/ÄGF-C, followed by corrections from the students, two questions were excluded, because the answers offered were not corresponding to the MCQ’s stem. Finally, 426 questions remained and were analyzed.

The subjects covered by the 426 questions concerned the diagnosis of psychiatric diseases (49.1 %), their therapies (29.6 %) and their etiology and pathogenesis (21.4 %). 18 questions covered two subjects (Table  1 ).

Significantly more items concerned the diagnosis of psychiatric diseases than their therapies ( p  < .001, Chi-Square Test); 63.3 % of the students offered at least one item regarding diagnosis and one item regarding therapy in their exercise.

Among the therapy items, significantly more pharmacology items were offered than psychotherapy items (59 % versus 41 %; p  = .043, Chi-Square Test).

395 (92.7 %) of the questions were classified as Step 1-questions. Nevertheless, 199 (46.7 %) of the questions were elaborate. 421 (98.8 %) out of the 426 questions were One-Step questions, according to USMLE criteria (Table  1 ). From the 18 questions covering two subjects, 16 were Step 1-questions.

72.5 % of the questions were positively formulated, 27.5 % negatively. A significant difference was observed between the positively and negatively formulated questions regarding the number of right answers: Table  2 shows the distribution of the number of right answers, depending on the questions’ formulation. The students offered significantly more right answer possibilities per positive-formulated question than per negative-formulated questions ( p  < .001, Mann–Whitney U Test).

The positive-formulated questions had more often two or more right answers than the negative-formulated questions ( p  < .001, Chi-square value = 44.2).

The students also offered less answer possibilities per positive-formulated question than per negative-formulated question ( p  < .001, Mann–Whitney U Test). Further, Table  2 presents the distribution of the number of answers offered depending on the questions’ formulation. The proportion of questions with 4 answer possibilities instead of 5 is higher within the group of positive-formulated questions ( p  < .001, Chi-square value = 16.56). Regarding the proportion of elaborate questions depending on their formulation, there was no significant difference.

Twenty-nine (36.7 %) students offered only positively formulated questions. The students who formulated at least one question negatively (63.3 %) formulated 41.1 ± 22.4 % of their questions negatively.

Many more questions aiming on diagnosis

At the end of year 4, students of the MUV had had various lectures but hardly any actual experiences with therapies. This may explain why significantly more items concerned the diagnosis of psychiatric diseases than their therapies.

Among questions aiming on therapy, significantly more concerned pharmacotherapy than psychotherapy

Before Block 20 , the seminars concerning therapies in the MUV Curriculum were almost exclusively pharmacological. After successful attendance of Block 20 most students who did not have any personal experience of psychotherapy only had little insight into how psychotherapy is developing on the long-term and what psychotherapy can really provide to the patient. Psychotherapy associations were still loaded with old stereotypes [ 13 , 16 ]. This could explain why significantly more therapy questions addressed pharmacology than psychotherapy.

A huge majority of Step 1 questions

The students mainly offered Step 1 questions. It can be questioned, whether the lack of case-oriented questions was an indication for insufficient clinical thinking by the students. An essential explanation could be that students lacked adequate patient contact until the end of year four. Indeed, MUV students were allowed to begin their practical experience after year two and eight compulsory clerkship weeks were scheduled before the beginning of year five [ 17 ]. Thus, Austrian medical students gained consistent clinical experience only after year four, with rotations in year five and the newly introduced Clinical Practical Year in year six. A European comparison of medical universities’ curricula showed that students of other countries spent earlier more time with patients: Dutch, French and German medical students began with a nursing training in year one and had 40, 10 and 4 months, respectively, more clerkship experience than Austrian students before entering year five [ 18 – 21 ]. French and Dutch universities are extremely centered on clinical thinking, with a total of 36 clerkship months in France and the weekly presence of patients from the first lectures on in Groningen [ 22 ]. Thus, it would be interesting to repeat a similar case-based exercise in these countries to explore if medical students at the same educational stage but with more practical experience are more likely to offer patient vignette items.

Students preferred to work with right facts and did not reject negatively worded questions

As negatively worded questions were usually banished from MCQ exams, it was interesting to observe that medical students did not reject them. In fact, negatively formulated questions are more likely to be misunderstood. Their understanding correlates to reading ability [ 23 ] and concentration. Although many guidelines [ 6 , 24 ] clearly advised to avoid negative items, the students generated 27.5 % of negatively formulated questions. Also Pick N format -questions with several right answers were offered by the students, despite the recommendations for this exercise: They offered significantly less total answer possibilities but significantly more right answers to positively worded questions than to negatively worded questions. Those results supported the hypothesis that the students preferred handling right content while keeping wrong content to a minimum.

Several possible reasons can be contemplated. When students lack confidence with a theme and try to avoid unsuitable answer possibilities, it can be more difficult to find four wrong answers to a positively worded question instead of several right answers, which may be listed in a book. Furthermore, some students may fear to think up wrong facts to avoid learning wrong content. Indeed, among positively worded items, 26.6 % were offered with 3 or more right answers, which never happened for negatively worded items (Table  2 ).

Notably, “right answer possibilities” of negatively worded items’ stems as well as “wrong answer possibilities” of positively worded items’ stems are actually “wrong facts”. For example, the right answer of the item “Which of the following symptoms does NOT belong to ICD-10 criteria of depression?” (Item 177) is the only “wrong fact” of the 5 answer possibilities. Writing the 4 “wrong answers” of this question, which are actually the ICD-10 criteria for depression, can help the students learn these diagnostic criteria. On the contrary, the “right answers” to a positively worded item such as “Which vegetative symptoms are related to panic attacks?” (Item 121) are the true facts.

Finally, the students’ interest for right facts supports the theory that a positive approach, positive emotions and curiosity are favorable to learning processes. Indeed, asking for right content is a natural way of learning, already used by children from the very early age. The inborn curiosity — urge to explain the unexpected [ 25 ], need to resolve uncertainty [ 26 ] or urge to know more [ 27 ]— is shown by the amount of questions asked by children [ 28 , 29 ]. The students’ way to ask for right contents appears very close to this original learning process.

The inputs of developmental psychology, cognitive psychology as well as of neurosciences underline this hypothesis. Bower presented influences of affect on cognitive processes: He showed a powerful effect of people’s mood on their free associations to neutral words and better learning abilities regarding incidents congruent with their mood [ 30 ]. Growing neurophysiological knowledge confirmed the close relation between concentration, learning and emotions — basic psychic functions necessitating the same brain structures. The amygdala, connected to major limbic structures (e.g. pre-frontal cortex, hippocampus, ventral striatum), plays a major role in affect regulation as well as in learning processes [ 15 ], and the hippocampus, essential to explicit learning, is highly influenced by stress, presenting one of the highest concentrations of glucocorticoid receptors in the brain [ 31 ]. Stress diminishes the synaptic plasticity within the hippocampus [ 32 ], plasticity which is necessary to long-term memory.

Neuroscientific research also underlined the interdependence of cognitive ability and affect regulation. Salas showed on a patient after an ischemic stroke event with prefrontal cortex damage that, due to executive impairment and increased emotional reactivity, cognitive resources could not allow self-modulation and reappraising of negative affects anymore [ 33 ].

Considering this interdependence, right contents might be related to a positive attitude and positive affects among the students. It could be interesting to further research on this relation as well as on the students’ motivations concerning the formulation of the questions.

The combination of those reasons probably explains why the students offered significantly more wrong answers to negatively worded items and more right answers to positively worded items, both resulting in the use of more right facts. All the students’ assessment questions and associated feedback were used to create a new database at the MUV trying to integrate more right facts in case-based learning exercises in the future.

The main limitation concerns the small sample size and the focus on only one curriculum element. Further studies with convenient sampling should include other medical fields and bridge the gap to learning outcome research.

The evaluation of the questions offered by medical students in their fourth year at the MUV showed that the students were much more confident with items aiming on diagnosis. Among items aiming on therapy, they proved to be more confident with pharmacotherapy than with psychotherapy. These results, together with the improving evaluation of the Block 20 after introducing CBL exercises and the international awareness that case-based questioning have a positive steering effect on the learning process and foster the acquisition of associative and procedural knowledge, should encourage the further development of affective positively involving case-based exercises, especially with a focus on clinical reasoning and therapy-oriented thinking.

The development of bedside teaching and the implementation of clerkships from the first year of studies (e.g. a 4-week practical nursing training) could also be considered in order to stimulate earlier patient-centered thinking of the students of the MUV. A comparison with the level of clinical reasoning of medical students from countries where more practical experience is scheduled during the first year of study would be interesting.

Concerning assessment methods and particularly the formulation of case-based questions, the students did not reject negatively formulated questions, but showed a tendency to prefer working with right contents, while keeping wrong content to a minimum. This preference could be further explored and considered in the future for the formulation of MCQs in case-based exercises.

Availability of supporting data

Data of the patients’ cases, on which the MCQs created by the students were based on, can be found in the textbook of the curriculum element and lectures [ 15 ] and via the Moodle website of the Medical University of Vienna [ 34 ]. The Moodle website is available for students and teachers of the Medical University of Vienna with their username and password. The analyzed and anonymous datasets including the MCQs [ 34 ] are accessible on request directly from the authors.

Abbreviations

Case-based learning

Extended Matching Items

• Multiple Choice Question

Medical University of Vienna

National Board of Medical Examiners

United States Medical Licensing Examination

Reid WA, Duvall E, Evans P. Relationship between assessment results and approaches to learning and studying in Year Two medical students. Med Educ. 2007;41:754–62. doi: 10.1111/j.1365-2923.2007.02801.x .

Article   Google Scholar  

Al-Wardy NM. Assessment methods in undergraduate medical education. Sultan Qaboos Univ Med J. 2010;10:203–9.

Google Scholar  

Epstein RM. Assessment in Medical Education. N Engl J Med. 2007;356:387–96. doi: 10.1056/NEJMra054784 .

Schuwirth LWT, van der Vleuten CPM. Different written assessment methods: what can be said about their strengths and weaknesses? Med Educ. 2004;38:974–9. doi: 10.1111/j.1365-2929.2004.01916.x .

Gajjar S, Sharma R, Kumar P, Rana M. Item and Test Analysis to Identify Quality Multiple Choice Questions (MCQs) from an Assessment of Medical Students of Ahmedabad, Gujarat. Indian J Community Med. 2014;39:17–20. doi: 10.4103/0970-0218.126347 .

Case SM, Swanson DB. National Board of Medical Examiners, Constructing Written Test Questions For the Basic and Clinical Sciences, Third Edition (revised). Philadelphia, USA: National Board of Medical Examiners® (NBME®); 2002.

Schmidmaier R, Eiber S, Ebersbach R, Schiller M, Hege I, Holzer M, et al. Learning the facts in medical school is not enough: which factors predict successful application of procedural knowledge in a laboratory setting? BMC Med Educ. 2013;13:28. doi: 10.1186/1472-6920-13-28 .

United States Medical Licensing Examination ®, (2015). http://www.usmle.org/ (Accessed January 29, 2016).

Thistlethwaite JE, Davies D, Ekeocha S, Kidd JM, MacDougall C, Matthews P, et al. The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23. Med Teach. 2012;34:e421–44. doi: 10.3109/0142159X.2012.680939 .

Medizinische Universität Wien, Management Summary, Curriculumelementevaluation SS 2013, 2013. http://www.meduniwien.ac.at/homepage/content/organisation/dienstleistungseinrichtungen-und-stabstellen/evaluation-und-qualitaetsmanagement/evaluation/curriculumelementevaluation-online/ . (Accessed January 29, 2016)

Medizinische Universität Wien, Management Summary, Curriculumelementevaluation SS 2014, 2014. http://www.meduniwien.ac.at/homepage/content/organisation/dienstleistungseinrichtungen-und-stabstellen/evaluation-und-qualitaetsmanagement/evaluation/curriculumelementevaluation-online/ . (Accessed January 29, 2016)

Medizinische Universität Wien, (2015). https://studyguide.meduniwien.ac.at/curriculum/n202-2014/?state=0-65824-3725/block-20-Psychische-Funktionen-in-Gesundheit-Und-Krankheit-Aerztliche-Gespraechsfuehrung-C (Accessed January 29, 2016).

Löffler-Stastka H, Blüml V, Ponocny-Seliger E, Hodal M, Jandl-Jager E, Springer-Kremser M. Students’ Attitudes Towards Psychotherapy : Changes After a Course on Psychic Functions in Health and Illness. Psychother Psych Med. 2010;60(3-4):118–25.

B.R. Turk, R. Krexner, F. Otto, T. Wrba, H. Löffler-Stastka, Not the ghost in the machine: transforming patient data into e-learning cases within a case-based blended learning framework for medical education, Procedia - Soc Behav Sci. 2015;186:713–725.

H. Löffler-Stastka, S. Doering, Psychische Funktionen in Gesundheit und Krankheit, 10th ed., Facultas Universitätsverlag, Wien; 2014.

H. Löffler-Stastka, V. Blüml, M. Hodal, E. Ponocny-Seliger, Attitude of Austrian students toward psychotherapy. Int J Med I. 2008;1(3):110–115.

Medizinische Universität Wien, Curriculum für das Diplomstudium Humanmedizin Konsolidierte Fassung : Stand Oktober 2013, 2013.

Maastricht University- Faculty of Health Medicine and Life Sciences, Maastricht Medical Curriculum, 2014–2015 Bachelor, (2015) 2014–2015, The Netherlands; 2015.

le ministre de la défense et la ministre de l’enseignement supérieur et de la recherche La ministre des affaires sociales et de la santé, Arrêté du 8 avril 2013 relatif au régime des études en vue du premier et du deuxième cycle des études médicales, JORF n°0095, (2013).

Medizinische Universität Heidelberg, Approbationsordnung für Ärzte, Stand 2013, 2013.

University of Groningen, (2015). Http://www.rug.nl/masters/medicine/programme (Accessed January 29, 2016).

J.B.M. Kuks, The bachelor-master structure (two-cycle curriculum) according to the Bologna agreement: a Dutch experience., GMS Z. Med. Ausbild. 27 (2010) Doc33. doi: 10.3205/zma000670 .

Weems GH, Onwuegbuzie AJ, Collins KMT. The Role of Reading Comprehension in Responses to Positively and Negatively Worded Items on Rating Scales. Eval Res Educ. 2006;19:3–20. doi: 10.1080/09500790608668322 .

R. Krebs, Anleitung zur Herstellung von MC - Fragen und MC - Prüfungen für die ärztliche Ausbildung, 2004.

J. Piaget, The psychology of intelligence., Totowa, NJ: Littlefield, Adams; 1960.

Kagan J. Motives and development. J Pers Soc Psychol. 1972;22(1):51–66. doi: 10.1037/h0032356 .

Engel S. Children’s Need to Know : Curiosity in Schools. Harv Educ Rev. 2011;81:625–46.

W. Labov, T. Labov, Learning the syntax of questions. In: Recent Advances in the Psychology of Language (pp.1–44), Springer US, 1978. doi: 10.1007/978-1-4684-2532-1 .

B. Tizard, M. Hughes, Young Children Learning, Harvard University Press, Cambridge, Massachusetts, United States of America; 1985.

Bower GH. Mood and Memory. Am Psychol. 1981;36(2):129–48.

McEwen BS. Stress and hippocampal plasticity. Annu Rev Neurosci. 1999;22:105–22. doi: 10.1146/annurev.neuro.22.1.105 .

McEwen BS. Sex, stress and the hippocampus: allostasis, allostatic load and the aging process. Neurobiol Aging. 2002;23:921–39.

Salas CE, Radovic D, Yuen KSL, Yeates GN, Castro O, Turnbull OH. “Opening an emotional dimension in me”: changes in emotional reactivity and emotion regulation in a case of executive impairment after left fronto-parietal damage. Bull Menninger Clin. 2014;78:301–34. doi: 10.1521/bumc.2014.78.4.301 .

Medizinische Universität Wien, https://moodle.meduniwien.ac.at/course/view.php?id=260&section=1 , in https://moodle.meduniwien.ac.at/login/index.php , (2015) (Accessed January 29, 2016).

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Prof. Dr. Michel Slama.

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Department for Psychoanalysis and Psychotherapy, Advanced Postgraduate Program for Psychotherapy Research, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria

Magalie Chéron & Henriette Löffler-Stastka

Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria

Mirlinda Ademi

Department of Anaesthesia, General Intensive Care and Pain Therapy, Medical University Vienna, Vienna, Austria

Felix Kraft

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MC carried out the study, performed the statistical analysis and drafted the manuscript. MA performed the statistical analysis and helped to draft the manuscript. FK participated in the design of the study and statistical analysis. HLS conceived of the study, participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.

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Chéron, M., Ademi, M., Kraft, F. et al. Case-based learning and multiple choice questioning methods favored by students. BMC Med Educ 16 , 41 (2016). https://doi.org/10.1186/s12909-016-0564-x

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Multiple Choice Questions

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A multiple choice question comprises of a stem, the correct answer/s and the distractors.

• A stem, that’s the question i.e. a problem or an incomplete statement - Make sure that you create a crisp, grammatically error-free and simple stem which has relevant information.
• The correct answer - This should be relevant to the stem and shouldn't consist of too many qualifiers like "always" and "some”. Use phrases as options when the stem is an incomplete statement.
• The other incorrect responses which are called ‘distractors’ - Ideally, create 4 distractors and should be in line with the correct answer. These distractors should usually be common misconceptions that your target audience may have.

Types of Multiple Choice Questions with Examples

The primary bifurcation of these questions is based on the number of answer options the respondents can select while responding the survey. So, single choice questions and multiple choice (multiple answer) questions are the two available main question types.

Single Select Multiple Choice Question

Matrix Table Multiple Choice Question with Check Boxes

Spreadsheet based Multiple Choice Questions:

Multiple choice questions are those question types that can create a big impact on your research by allowing you to measure the customers’ opinions and their preference merely at a glance. Multiple choice questions are an amazing choice for the following:

• Questions that are asked to know what stands out most with the users or customers.
• Gauging preference for specific designs or elements of your product.
• When you need to ask a certain question to evaluate the content.

Here are the 3 amazing tips to writing multiple choice questions:

• Don’t forget to include “other” option: While writing the multiple choice questions it is advisable to include the “other” option so that the respondents have a say to express their opinion if they don’t like the particular answer options that have been given by the survey creator.
• Provide clear answer options: It’s important to put distinctive clear answer options to the question that is being asked. If all the answers bleed together and there is no clarity then the respondents will be confused and not be able to choose the most appropriate answers from the options.
• Avoid asking yes/no questions: If simply direct questions are asked then respondents will have little options to answer the questions, always give answer options that give respondents ample choices to choose from.

Advantages of Multiple Choice Questions

Imagine the pain a respondent goes through while having to type in answers when they can simply answer the questions at the click of a button. Here is where multiple choice lessens the complications.

Many-a-times the survey creator would want to ask straightforward questions to the respondent, the best practice is to provide the choices instead of them coming up with answers, this in-turn saves their valuable time.

Surveys are often developed with respondents in mind, how will they answer the questions? This is where multiple choice gives a specific structure to responses, therefore becomes the best choice.

Let’s say at your workplace you receive a survey asking about the best restaurant, to host the Christmas party. Honestly speaking giving specific options isn’t going to hurt, rather, as a surveyor, you are sure that the answer will be from one of the options given to the respondents.

It will be easier for the surveyor to analyze the data as it will be free from any errors (as respondents won’t be typing in answers) and the surveyor would atleast know that not a random restaurant would be chosen.

One of the positives of multiple choice options is that they help respondents understand how they should answer. In this manner, the surveyor can choose how generalist or specific the responses need to be.

At all times, the surveyor needs to be careful on the choice of question in order to be able to receive responses that are easy to analyze.

It is estimated that 1 out of 5 people take surveys on handheld devices like mobile phones or tablets. Considering the fact that there is no mouse or keyboard to use, multiple choice questions make it easier for the respondent to choose as there is no scrolling involved.

Therefore, in a survey you might end up answering a number of multiple choice questions and for a good reason, easy for the respondents to answer and convenient for the surveyor to collect data.

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Multiple Choice Questions : With Types and Examples

Market Research Specialist

Emma David, a seasoned market research professional, specializes in employee engagement, survey administration, and data management. Her expertise in leveraging data for informed decisions has positively impacted several brands, enhancing their market position.

Whether it is choosing your next holiday destination or an ice cream flavor, making a choice is sometimes the most difficult thing in life. However, if there is anything that can make such decisions easier, it is a list of options. Well, multiple-choice questions  are about that!

A well-framed multiple-choice question survey follows a structured format, presenting respondents with clear and concise answer choices. This format ensures consistency in the response collection process, making it easier to analyze and interpret the data.However, there is a challenge! How do you make your MCQ questions more interactive and grab the attention of your target audience?

Well, to help you rise above this challenge, we have created a list of different types of multiple-choice question  along with their examples. Whether you are an examiner or a research analyst, this blog will prepare you to ask the right MCQs at the right time and engage your audience.

Let’s go!

What Are Multiple Choice Questions (MCQs)?

Multiple choice questions are one of the most popular question types that present a question or statement with a list of possible answers. In most cases, the individual is allowed to select a single option. However, they can even choose multiple options if such instructions are given.

MCQs are very helpful in collecting information and feedback from a target audience.

For example, many businesses share the popular MCQ question:

Which of the following aspects of our product/service did you find most impressive?

A) Speed and Efficiency B) User-Friendly Interface C) Quality and Reliability D) Customer Support E) Pricing and Value for Money.

Multiple choice questions are close-ended questions as the respondent has a limited number of options to choose from. In addition to this, MCQs have a variety of applications — they can be used in surveys, questionnaires, polls, forms, academic tests, quizzes, and much more.

A multiple-choice question and answer consist of several important parts:

Stem: The stem refers to the main question or statement. The stem should be clear, straightforward, and written in simple language.

Distractors: Distractors are incorrect options that are used to distract and challenge the respondent. You must carefully pick the distractors not to seem too obvious.

Answer: This is the correct answer to the stem or question. There may be more than one correct answer in some cases, and the respondent is allowed to make multiple selections.

How to Write a Multiple-Choice Question?

Creating an effective multiple-choice question (MCQ) involves careful planning and construction to ensure it accurately assesses knowledge, comprehension, or application skills. Here’s a detailed guide on how to craft a multiple-choice question:

1. Define the Objective

Start by determining what the question is intended to assess. Is it factual knowledge, conceptual understanding, application of skills, or analysis and evaluation? Clearly defining the objective will guide the development of both the stem and the distractors.

2. Write the Stem

The stem is the part of the MCQ that poses the question or problem. It should be clearly written, focused, and free of unnecessary information. Ensure the stem presents a single, clear problem or question that can be understood without reading the options first.

• Direct Question : Pose a direct question that requires an answer.
• Incomplete Statement : Present a statement that the respondent must complete with the correct option.
• Scenario-based : Provide a scenario or case study that leads to a question, testing application, and analysis skills.

3. Develop the Options

• Key : This is the correct answer to the question. It should be indisputably correct and fully supported by the content being tested.
• Distractors : These are the incorrect answers. Good distractors are plausible, based on common misconceptions, errors, or closely related concepts, making the question challenging but fair.

4. Maintain Option Consistency

• Length and Form : All options should be similar in length and complexity. An outlier can often be mistakenly identified as the correct answer.
• Content : Options should be homogeneous in content type (all dates, all theories, etc.) to avoid clues to the correct answer.
• Grammar : Ensure that grammatically, all options fit seamlessly with the stem.

5. Avoid Common Pitfalls

• Avoid Absolutes : Words like “always” or “never” can make distractors obviously wrong.
• Randomize Option Order : The position of the correct answer should vary from question to question.
• Use “All of the Above” and “None of the Above” Sparingly : These can sometimes give away the answer or invalidate the question if not used carefully.

6. Review and Revise

After drafting, review the question to ensure it meets the objective, is clear and unambiguous, and that the distractors are plausible but not too similar to the correct answer. Pilot testing with a small group can help identify issues before the MCQ is used more widely.

7. Consider Higher-Order Thinking

Whenever possible, design MCQs that test higher-order thinking skills rather than mere recall of facts. Questions that require analysis, synthesis, and evaluation to arrive at the answer are more challenging and provide a better assessment of the respondent’s understanding and ability to apply knowledge.

12 Types of Multiple Choice Questions

If you thought that a multiple-choice question only includes a typical question with four options, you might be wrong. You will be surprised to know that at least 12 different types of MCQs can be used for different purposes. Let’s explore them right away.

1. Yes or No Multiple Choice Questions

This is a widely used multiple-choice question that offers two obvious options – “Yes” or “No”. It can be used to ask a direct question such as ‘Would you recommend our business to your friends or family members?’ or ‘Does our product serve your purpose?’.

One demerit of this question is that although you can capture feedback, you will not know the reason behind why someone gave a “no” or a “yes” as an answer. Therefore, to make sense of your data, you also need to add an open-ended question.

Read More: How to Set up Branching in a Survey

2. True or False Multiple Choice Questions

The “True” or “False” questions are some of the most commonly used multiple-choice questions. It includes the stem (question or statement) and two answer options – True and False. These questions are used to test critical thinking and evaluate the respondent’s knowledge by challenging them to choose the correct option.

So if you wish to engage your audience in a challenging game or teach them something new, this is the way to go.

3. Odd One Out Multiple Choice Questions

The “odd one out” question provides several options to respondents and asks them to choose an option that does not match the others or seems the most “odd.”

Such questions are used to test the ability of people to form relationships between ideas. The odd one out question is quite popular among school students. Let’s look at the example below to gain more clarity.

4. Image-Based Multiple Choice Questions

As the name suggests, this type of MCQ presents two or more images as response options. To answer this question, the respondent can select a single image or multiple images if it is specified. Image-based questionnaires are visually appealing, highly interactive, and can be used to engage your target audience.

These questions are used where visual representation is needed. For example, Google offers a service called ReCAPTCHA that uses smart image-based questions to identify humans and prevent bots from causing security threats.

5. Best Answer Multiple Choice Questions

This type of question can be quite challenging for people to answer. But why? Well, in most cases, the options include more than one answer that might seem correct at first glance. However, the correct answer is the one that is the truest.

The “best answer” question can be used to understand what people think or perceive about different situations. Let’s understand this better with this multiple choice question example:

6. Single Select Multiple Choice Questions

This is a common type of multiple-choice question where the respondent is allowed to select a single option from a list of options. The dropdown menu is a great example of a single select question.

Single-select questions work best when presenting a long list of options. Whether someone is on their smartphone or laptop, the respondents can easily scroll through the options and select the right answer.

7. Multiple Select Questions

Unlike single-select questions, the respondent can select more than one option in multiple select questions. While taking orders, such questionnaires are often used by restaurants as the customers can easily customize their meals.

In some cases, these questions also offer the “Select All” or “All of the Above” option so that respondents can easily select this option without having to pick and choose specific options. Multiple select questions offer more freedom and flexibility to respondents compared to other types of MCQ questions.

8. Star Rating Multiple Choice Questions

Star rating is another popular multiple-choice question type that allows respondents to answer on a rating scale . Respondents are usually offered a 1-5 or 1-7 rating scale, where 5 or 7 stars denote the highest satisfaction. Such questions are quite interactive, easy to answer and work great on mobile devices.

These types of questions are usually used by businesses to get customer reviews on their products or services. For example, you must have received a survey asking you to rate your cab ride experience once you reached your destination. Instead of stars, you can even use other types of rating scales such as “Thumbs up” or “Smileys”

9. Matrix Table Multiple Choice Questions

A matrix table question allows you to ask multiple questions or multiple parts of a single question. For example, you can take feedback about the various elements of your website – design, user interface, image quality, browsing experience, product descriptions, payment options, etc.

The multiple questions or elements are accompanied by a three-point or five-point Likert scale . However, if not executed right, matrix table questions can confuse your respondents. Here is a sample multiple-choice question with answer options:

10. Slider Multiple Choice Questions

This is another type of multiple-choice question in which the respondent can use a slider to answer the given question. The slider can be adjusted to a numeric value that best describes their answer.

For example, you can share the classic NPS question : “How likely are you to recommend our brand to your friends or colleagues?” The customers can adjust the slider and rate their answers on a scale of 1-10. For a better understanding, you can look at this multiple-choice example below:

11. Ranking Multiple Choice Questions

A ranking multiple choice question allows respondents to rank the answer options based on their importance or priority. The respondent can first compare all the options against each other and then rank them accordingly.

To make this question work, you will have to present a numerical drop-down box for each answer option. This will help the respondent allocate the correct numerical value to each option. Such questions can be helpful when you wish to know a person’s opinion or perception about particular topics.

12. Drag & Drop Multiple Choice Questions

In these types of multiple-choice questions, the respondent can drag and drop the answer options to arrange them in the most suitable order. This is quite similar to a ranking question; however, the respondent can simply drag and drop options to achieve the best order instead of assigning a numerical value.

The drag-and-drop questions are quite interactive in nature and can lead to a fun survey experience for your customers. Educators can also use them to teach young kids. Let’s take a look at this example below:

Watch: How to Collect Customer Feedback

Learn how to create your own grid-of-choice questions here: How to Create a Grid of Choices

Advantages of Multiple Choice Questions

Well, it will not be wrong to say that a multiple-choice questionnaire means multiple benefits. Let’s explore some of the top advantages of MCQs.

1. Convenient

Imagine you ordered food online and received it well on time. Now, the app asks you to rate the delivery partner on a scale of 1-5. By spending just a couple of seconds, you can rate the delivery partner and appreciate them for a job well done. Yes, MCQs are really that convenient!

Whether you are taking an application form or sharing feedback with your favorite brand, you can fill MCQs anytime and from anywhere. As long as there are fewer questions to answer, it will not take a toll on your brain or body.

2. Avoid Subjective Opinions

There are situations when you don’t need the subjective opinions of your respondents. For example, if you wish to know the most popular election candidate, you can simply present the names of the people who are contesting. Taking subjective opinions about the importance of elections or democracy will not serve any purpose here.

With multiple-choice questions, you can get objective data that is both observable as well as measurable. This helps you achieve your research goals faster.

3. Takes Less Time to Complete

Multiple-choice questionnaires take less time to complete in comparison to open-ended questions . For instance, if students are asked to write an essay in a test instead of answering MCQs, they will take more time.

Similarly, a business can share short MCQ surveys with customers and allow them to complete them at their convenience. When customers know that such questions will take less time to complete, the business can enjoy higher survey response rates .

4. Makes Data Analysis Simpler

With multiple-choice questions, you can easily automate your data analysis process. For example, in the case of student tests, automated grading can help teachers evaluate tests and grade students on a larger scale. Even if a thousand students are given the same test, grading can be easily done.

Moreover, when people are made to type their answers, there can be grammatical or typographical errors. However, you can reduce human errors and make data analysis easier when you provide selected response options.

Disadvantages of Multiple Choice Questions

There are pros and cons to everything, and MCQs are no exception. Here are some common disadvantages of multiple-choice questions:

1. People Can Get Lucky

People who have no idea about a question might get lucky while answering an MCQ. During a test, a student can randomly choose an option (out of four), and there is a 25% chance that it is the correct answer.

Even if someone decides to select the option “A” for every question, the person will get some correct answers for sure, even if they would normally get 0% in other types of questions.

2. Can Take Time to Develop

There are certain types of multiple-choice questions where you need to choose every response option carefully. Giving more thought to something only means spending more time and effort.

For example, for a maths test, you need to strategically choose potential answers to avoid making the correct answer seem too obvious. Framing such questions can take more time than writing open-ended or fill-in-the-blank questions.

3. MCQs Lack Qualitative Data

With multiple-choice questions, you can understand that a customer had an unsatisfactory experience with your brand. However, you cannot understand the “why” behind it. In order to see the complete picture, you need to use the right mix of both open and closed-ended questions.

MCQs may not help you capture qualitative data in the form of subjective opinions, perceptions, stories, experiences, and more.

Create the Best Multiple-Choice Questions

Due to their versatile nature, multiple-choice questions have gained popularity in education, market research, customer feedback, product development, and many others.

To create the best multiple-choice questionnaire, you need to provide accurate and relevant answer options, keep the language simple, and add the “others” option whenever possible. With well-framed MCQs, you can collect comprehensive data and research your target audience faster.

With ProProfs Survey Maker , you can go for multiple-choice or 20 other question-types such as rating scale, NPS scale, text box, etc. You can also choose from our library of 1000,000+ ready-to-use questions or simply create one from scratch. Customize the various elements of your question, add branching to answers, and share your questionnaire via email, social media, or embed on your website. Yes, collecting the right information is really that simple now!

About the author

Emma David is a seasoned market research professional with 8+ years of experience. Having kick-started her journey in research, she has developed rich expertise in employee engagement, survey creation and administration, and data management. Emma believes in the power of data to shape business performance positively. She continues to help brands and businesses make strategic decisions and improve their market standing through her understanding of research methodologies.

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Article Contents

Answer to part 1, answer to part 2, answer to part 3, answer to part 4, answer to part 5.

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Educational Case: A 57-year-old man with chest pain

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Nikhil Aggarwal, Subothini Selvendran, Vassilios Vassiliou, Educational Case: A 57-year-old man with chest pain, Oxford Medical Case Reports , Volume 2016, Issue 4, April 2016, Pages 62–65, https://doi.org/10.1093/omcr/omw008

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This is an educational case report including multiple choice questions and their answers. For the best educational experience we recommend the interactive web version of the exercise which is available via the following link: http://www.oxfordjournals.org/our_journals/omcr/ec01p1.html

A 57 year-old male lorry driver, presented to his local emergency department with a 20-minute episode of diaphoresis and chest pain. The chest pain was central, radiating to the left arm and crushing in nature. The pain settled promptly following 300 mg aspirin orally and 800 mcg glyceryl trinitrate (GTN) spray sublingually administered by paramedics in the community. He smoked 20 cigarettes daily (38 pack years) but was not aware of any other cardiovascular risk factors. On examination he appeared comfortable and was able to complete sentences fully. There were no heart murmurs present on cardiac auscultation. Blood pressure was 180/105 mmHg, heart rate was 83 bpm and regular, oxygen saturation was 97%.

What is the most likely diagnosis?

An ECG was requested and is shown in figure 1.

How would you manage the patient? (The patient has already received 300 mg aspirin).

30 minutes later the patient's chest pain returned with greater intensity whilst waiting in the emergency department. Now, he described the pain as though “an elephant is sitting on his chest”. The nurse has already done an ECG by the time you were called to see him. This is shown in figure 2.

ECG on admission.

ECG 30 minutes after admission.

What would be the optimal management for this patient?

He was taken to the catheterization lab where the left anterior descending coronary artery (LAD) was shown to be completely occluded. Following successful percutaneous intervention and one drug eluding stent implantation in the LAD normal flow is restored (Thrombosis in myocardial infarction, TIMI = 3). 72 hours later, he is ready to be discharged home. The patient is keen to return to work and asks when he could do so.

When would you advise him that he could return to work?

One week later, he receives a letter informing him that he is required to attend cardiac rehabilitation. The patient is confused as to what cardiac rehabilitation entails, although he does remember a nurse discussing this with him briefly before he was discharged. He phones the hospital in order to get some more information.

Which of the following can be addressed during cardiac rehabilitation?

A - Acute coronary syndrome

Although the presentation could be attributable to any of the above differential diagnoses, the most likely etiology given the clinical picture and risk factors is one of cardiac ischemia. Risk factors include gender, smoking status and age making the diagnosis of acute coronary syndrome the most likely one. The broad differential diagnosis in patients presenting with chest pain has been discussed extensively in the medical literature. An old but relevant review can be found freely available 1 as well as more recent reviews. 2 , 3

C - Atorvastatin 80 mg, Clopidogrel 300 mcg, GTN 500 mcg, Ramipril 2.5 mg,

In patients with ACS, medications can be tailored to the individual patient. Some medications have symptomatic benefit but some also have prognostic benefit. Aspirin 4 , Clopidogrel 5 , Atenolol 6 and Atorvastatin 7 have been found to improve prognosis significantly. ACE inhibitors have also been found to improve left ventricular modeling and function after an MI. 8 , 9 Furthermore, GTN 10 and morphine 11 have been found to be of only significant symptomatic benefit.

Oxygen should only to be used when saturations <95% and at the lowest concentration required to keep saturations >95%. 12

There is no evidence that diltiazem, a calcium channel blocker, is of benefit. 13

His ECG in figure 1 does not fulfil ST elevation myocardial infarction (STEMI) criteria and he should therefore be managed as a Non-STEMI. He would benefit prognostically from beta-blockade however his heart rate is only 42 bpm and therefore this is contraindicated. He should receive a loading dose of clopidogrel (300 mg) followed by daily maintenance dose (75 mg). 14 , 15 He might not require GTN if he is pain-free but out of the available answers 3 is the most correct.

D - Proceed to coronary angiography

The ECG shows ST elevation in leads V2-V6 and confirms an anterolateral STEMI, which suggests a completely occluded LAD. This ECG fulfils the criteria to initiate reperfusion therapy which traditionally require one of the three to be present: According to guidance, if the patient can undergo coronary angiography within 120 minutes from the onset of chest pain, then this represents the optimal management. If it is not possible to undergo coronary angiography and potentially percutaneous intervention within 2 hours, then thrombolysis is considered an acceptable alternative. 12 , 16

≥ 1 mm of ST change in at least two contiguous limb leads (II, III, AVF, I, AVL).

≥ 2 mm of ST change in at least two contiguous chest leads (V1-V6).

New left bundle branch block.

GTN and morphine administration can be considered in parallel but they do not have a prognostic benefit.

E - Not before an exercise test

This patient is a lorry driver and therefore has a professional heavy vehicle driving license. The regulation for driving initiation in a lorry driver following a NSTEMI/ STEMI may be different in various countries and therefore the local regulations should be followed.

In the UK, a lorry driver holds a category 2 driving license. He should therefore refrain from driving a lorry for at least 6 weeks and can only return to driving if he completes successfully an exercise evaluation. An exercise evaluation is performed on a bicycle or treadmill. Drivers should be able to complete 3 stages of the standard Bruce protocol 17 or equivalent (e.g. Myocardial perfusion scan) safely, having refrained from taking anti-anginal medication for 48 hours and should remain free from signs of cardiovascular dysfunction during the test, notably: angina pectoris, syncope, hypotension, sustained ventricular tachycardia, and/or electrocardiographic ST segment shift which is considered as being indicative of myocardial ischemia (usually >2 mm horizontal or down-sloping) during exercise or the recovery period. 18

For a standard car driving license (category 1), driving can resume one week after successful intervention providing that no other revascularization is planned within 4 weeks; left ventricular ejection fraction (LVEF) is at least 40% prior to hospital discharge and there is no other disqualifying condition.

Therefore if this patent was in the UK, he could restart driving a normal car one week later assuming an echocardiogram confirmed an EF > 40%. However, he could only continue lorry driving once he has passed the required tests. 18

E - All of the above

Cardiac rehabilitation bridges the gap between hospitals and patients' homes. The cardiac rehabilitation team consists of various healthcare professions and the programme is started during hospital admission or after diagnosis. Its aim is to educate patients about their cardiac condition in order to help them adopt a healthier lifestyle. This includes educating patients' about their diet, exercise, risk factors associated with their condition such as smoking and alcohol intake and finally, about the medication recommended. There is good evidence that adherence to cardiac rehabilitation programmes improves survival and leads to a reduction in future cardiovascular events.​ 19 , 20

Oille JA . Differential diagnosis of pain in the chest . Can Med Assoc J . 1937 ; 37 (3) : 209 – 216 . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC536075/ .

Google Scholar

Lee TH , Goldman L . Evaluation of the patient with acute chest pain . N Engl J Med . 2000 ; 342 (16) : 1187 – 1195 . http://www.nejm.org/doi/full/10.1056/NEJM200004203421607 .

Douglas PS , Ginsburg GS . The evaluation of chest pain in women . N Engl J Med . 1996 ; 334 (20) : 1311 – 1315 . http://www.nejm.org/doi/full/10.1056/NEJM199605163342007 .

Baigent C , Collins R , Appleby P , Parish S , Sleight P , Peto R . ISIS-2: 10 year survival among patients with suspected acute myocardial infarction in randomised comparison of intravenous streptokinase, oral aspirin, both, or neither. the ISIS-2 (second international study of infarct survival) collaborative group . BMJ . 1998 ; 316 (7141) : 1337 – 1343 . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC28530/ .

Yusuf S , Zhao F , Mehta S , Chrolavicius S , Tognoni G , Fox K . Clopidogrel in unstable angina to prevent recurrent events trail investigators . effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation . N Engl J Med . 2001 ; 345 (7) : 494 – 502 . http://www.nejm.org/doi/full/10.1056/NEJMoa010746#t=articleTop .

Yusuf S , Peto R , Lewis J , Collins R , Sleight P . Beta blockade during and after myocardial infarction: An overview of the randomized trials . Prog Cardiovasc Dis . 1985 ; 27 (5) : 335 – 371 . http://www.sciencedirect.com/science/article/pii/S0033062085800037 .

Schwartz GG , Olsson AG , Ezekowitz MD et al.  . Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: The MIRACL study: A randomized controlled trial . JAMA . 2001 ; 285 (13) : 1711 – 1718 . http://jama.jamanetwork.com/article.aspx?articleid=193709 .

Pfeffer MA , Lamas GA , Vaughan DE , Parisi AF , Braunwald E . Effect of captopril on progressive ventricular dilatation after anterior myocardial infarction . N Engl J Med . 1988 ; 319 (2) : 80 – 86 . http://content.onlinejacc.org/article.aspx?articleid=1118054 .

Sharpe N , Smith H , Murphy J , Hannan S . Treatment of patients with symptomless left ventricular dysfunction after myocardial infarction . The Lancet . 1988 ; 331 (8580) : 255 – 259 . http://www.sciencedirect.com/science/article/pii/S0140673688903479 .

Ferreira JC , Mochly-Rosen D . Nitroglycerin use in myocardial infarction patients . Circ J . 2012 ; 76 (1) : 15 – 21 . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3527093/ .

Herlitz J , Hjalmarson A , Waagstein F . Treatment of pain in acute myocardial infarction . Br Heart J . 1989 ; 61 (1) : 9 – 13 . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1216614/ .

Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC), Steg PG, James SK, et al . ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation . Eur Heart J . 2012 ; 33 (20) : 2569 – 2619 . http://eurheartj.oxfordjournals.org/content/33/20/2569 .

The effect of diltiazem on mortality and reinfarction after myocardial infarction . the multicenter diltiazem postinfarction trial research group . N Engl J Med . 1988 ; 319 (7) : 385 – 392 . http://www.nejm.org/doi/full/10.1056/NEJM198808183190701 .

Jneid H , Anderson JL , Wright RS et al.  . 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/Non–ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update) A report of the american college of cardiology foundation/american heart association task force on practice guidelines . J Am Coll Cardiol . 2012 ; 60 (7) : 645 – 681 . http://circ.ahajournals.org/content/123/18/2022.full .

Hamm CW , Bassand JP , Agewall S et al.  . ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The task force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the european society of cardiology (ESC) . Eur Heart J . 2011 ; 32 (23) : 2999 – 3054 . http://eurheartj.oxfordjournals.org/content/32/23/2999.long .

O'Gara PT , Kushner FG , Ascheim DD et al.  . 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: Executive summary: A report of the american college of cardiology foundation/american heart association task force on practice guidelines . J Am Coll Cardiol . 2013 ; 61 (4) : 485 – 510 . http://content.onlinejacc.org/article.aspx?articleid=1486115 .

BRUCE RA , LOVEJOY FW Jr . Normal respiratory and circulatory pathways of adaptation in exercise . J Clin Invest . 1949 ; 28 (6 Pt 2) : 1423 – 1430 . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC439698/ .

DVLA . Https://Www.gov.uk/current-medical-guidelines-dvla-guidance-for-professionals-cardiovascular-chapter-appendix .

British Heart Foundation . Http://Www.bhf.org.uk/heart-health/living-with-heart-disease/cardiac-rehabilitation.aspx .

Kwan G , Balady GJ . Cardiac rehabilitation 2012: Advancing the field through emerging science . Circulation . 2012 ; 125 (7) : e369–73. http://circ.ahajournals.org/content/125/7/e369.full .

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Generation of medical case-based multiple-choice questions.

1. Introduction

1.1. historical background, 1.2. structure of a case-based mcq.

• The stem (sometimes the portion referred to as the “question”). This might consist of a simple question, but might also be more complex, and include a scenario and media. The key element in creating a robust multiple-choice question is to ensure that the stem is well-defined and focused. The stem of the query must contain the primary concept.
• Alternatives (sometime referred to as “options”). These include all the items, from which the user must select one.
• Answer (sometimes referred to as the “correct answer” or the “key”). This is one of the alternatives, and is the actual required answer to the question. The crucial characteristic is that the selected option deemed as accurate must be absolutely indisputable, without any doubt or debate. It is preferable to have a manuscript citation or reference on hand for verification purposes. When providing a correct answer, beware of using ambiguous phrases like “frequently”, “often”, “rarely”, or “sometimes”. These hints indicate that an answer is correct and demonstrate test-taking intelligence rather than subject content knowledge.
• Distractors. There are all the alternatives that are not the answer. From a cognitive perspective, it is acceptable to have two distractors. However, in health sciences testing, it is more common to have three or four distractors. Writing plausible distractors can be the most difficult aspect of developing a well-formulated examination.

1.3. Transition to Clinical Significance

1.4. emergence of case-based mcqs, 1.5. integration of technology, 2. the significance of case-based mcqs, 2.1. the integration of theory and practice, 2.2. evaluating higher-order cognitive abilities, 2.3. improving clinical readiness, 2.4. embracing contemporary pedagogical approaches, 2.5. the provision of objective assessment metrics, 2.6. enhancing proficiency in differential diagnosis abilities, 3. approaches for generating case-based mcqs, 3.1. generation through manual procedures.

• Selection of Topic: During the initial phase, educators execute a meticulous selection of a medical subject or issue that bears relevance to the curriculum, as indicated by Al-Rukban [ 7 ]. If the institution uses Learning Objectives, then these must also be noted to ensure that the questions are aligned with them.
• Development of Case Scenario: This phase entails the crafting of a patient scenario which could be derived from either authentic experiences or hypothetical situations, aiming to construct a contextual framework. Typical elements of a patient’s medical record integrate their medical history, vital statistics, laboratory results, and other pertinent information [ 14 ].
• Question Framing: The core objective of framing questions is to evaluate understanding, analysis, or application in connection with the presented case study [ 7 , 14 ].
• Distractor generation: Distractor conceptualization involves formulating conceivable incorrect alternatives (distractors) that are coherent and non-deceptive, a notion underscored by Al-Rukban and Kurdi [ 7 , 14 ].
• Validation: The refinement and validation of MCQs are optimized through a peer review, executed by educationalists and clinical experts. This collaborative methodology ascertains the enhancement of question clarity, accuracy, and pertinence [ 14 ].

3.2. Challenges of Manual Generation

3.3. the process of automated generation, 3.4. the advantages and obstacles associated with automated generation, 4. principles for designing case-based mcqs, 4.1. authenticity of cases, 4.2. precision and clarity in language, 4.3. pertinent and rigorous distractors, 4.4. incorporation of clinical reasoning, 4.5. facilitation of feedback, 4.6. conformity with educational objectives, 4.7. recurrent evaluation and validation, 5. validity and reliability of case-based mcqs, 5.1. validity of case-based mcqs.

• Content validity: This measures the extent to which the MCQs cover the topics and relevant clinical areas. It is important to select cases that show the many different situations that doctors might face [ 6 ].
• Criterion-related validity: This measures the extent to which the results from these MCQs match results from other tests measuring the same skills or knowledge. For example, you could check how well scores from a case-based MCQ test compare with scores from a hands-on clinical exam, following the ideas of Messick et al. [ 26 ]. Criterion-related validity can be further divided into concurrent validity (comparing to an established tool) and predictive validity (for predicting future outcomes) [ 27 ].
• Construct validity: This measures the extent to which the MCQs test the theoretical ideas that are supposed to be assessed. The questions should be able to effectively check if the intended theoretical concepts are understood by the students. For example, if a collection of MCQs are formulated with the intention of evaluating clinical reasoning abilities, it may be hypothesized that students who achieve higher scores on these assessments will possess superior clinical reasoning skills compared to those who obtain lower scores [ 28 ].

5.2. Reliability of Case-Based MCQs

• Test–retest reliability: Test–retest reliability refers to the assessment of the consistency of scores obtained by students when they take the same test on several occasions. According to Nunnally, a strong correlation between the MCQs indicates that they yield consistent outcomes throughout different time periods [ 29 ].
• Internal consistency: Internal consistency refers to the degree to which several items within an MCQ test produce consistent outcomes. Cronbach’s alpha is a frequently employed statistical measure for this particular objective. According to Nunnally, a high result, often over 0.7, signifies that the MCQs effectively assess the same underlying construct [ 29 ]. For test reliability, however, the Kuder–Richarson 20 (KR20) (when item difficulty is variable) and the KR21 (when the item difficulty is similar) are preferred [ 30 ].
• Inter-rater reliability: Inter-rater reliability is of utmost importance in situations where questions are open-ended and necessitate manual scoring. The measure assesses the level of consensus among several raters or examiners. According to Kurdi et al., a high coefficient of inter-rater reliability signifies a consistent scoring pattern among many examiners [ 6 ].

6. Challenges and Controversies in Case-Based MCQs

• Overemphasis on Recall: One potential issue with MCQs is the tendency to place excessive emphasis on recall. Although MCQs are effective in evaluating a wide range of content, there is a valid concern that they primarily measure memorization rather than comprehensive comprehension or practical application [ 3 ]. In order for case-based MCQs to be truly effective, it is imperative that they redirect their emphasis from mere memory to the domains of application and synthesis.
• The Importance of Misleading Distractors: The inclusion of effective distractors plays a vital role in enhancing the discriminatory capacity of MCQs. Nevertheless, it is worth noting that inadequately formulated distractors have the potential to deceive students, transforming questions into assessments of test-taking abilities rather than evaluating their clinical reasoning capabilities [ 31 ].
• Dependence on Stem Clarity: The importance of stem clarity in determining dependence is of utmost significance. The presence of ambiguous or unnecessarily lengthy stems in academic assessments may lead to unanticipated challenges, which could potentially put learners at a disadvantage [ 31 ].
• Cultural and Socio-Economic Biases: MCQs may unintentionally include cultural or socio-economic biases, thereby reflecting the perspectives of the individuals who authored the questions rather than universally accepted medical information. Kim and Zabelina (2015) argue that prejudices have the potential to create disadvantages for specific student groups [ 32 ].
• Over-Reliance on Single Best Answer: The practical situations encountered in the field of medicine rarely possess unequivocal resolutions. According to Scott et al. (2018), the utilization of single-best-answer MCQs may occasionally result in an oversimplification of intricate clinical settings [ 8 ].
• Security Concerns: Security concerns have emerged due to the widespread use of digital platforms and student collaboration tools, which have raised apprehensions over the security of exams and the potential for question-sharing. These concerns pose significant risks to the overall integrity of the assessment process [ 33 ].
• Technology Dependence: The integration of MCQs into digital platforms has led to a heightened reliance on technology. This presents difficulties pertaining to software malfunctions, user interface usability, and the issue of digital equity [ 34 ].

7. Future Directions

8. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

• Mujeeb, A.; Ghongane, B.; Pardeshi, M. Comparative assessment of multiple choice questions versus short essay questions in pharmacology examinations. Indian J. Med. Sci. 2010 , 64 , 118. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Bassett, M.H. Teaching Critical Thinking without (Much) Writing: Multiple-Choice and Metacognition. Teach. Theol. Relig. 2016 , 19 , 20–40. [ Google Scholar ] [ CrossRef ]
• Khan, M.-U.; Aljarallah, B.M. Evaluation of Modified Essay Questions (MEQ) and Multiple Choice Questions (MCQ) as a tool for Assessing the Cognitive Skills of Undergraduate Medical Students. Int. J. Health Sci. 2011 , 5 , 39–43. [ Google Scholar ]
• Leo, J.; Kurdi, G.; Matentzoglu, N.; Parsia, B.; Sattler, U.; Forge, S.; Donato, G.; Dowling, W. Ontology-Based Generation of Medical, Multi-term MCQs. Int. J. Artif. Intell. Educ. 2019 , 29 , 145–188. [ Google Scholar ] [ CrossRef ]
• Chéron, M.; Ademi, M.; Kraft, F.; Löffler-Stastka, H. Case-based learning and multiple choice questioning methods favored by students. BMC Med. Educ. 2016 , 16 , 41. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Kurdi, G.; Leo, J.; Parsia, B.; Sattler, U.; Al-Emari, S. A Systematic Review of Automatic Question Generation for Educational Purposes. Int. J. Artif. Intell. Educ. 2019 , 30 , 121–204. [ Google Scholar ] [ CrossRef ]
• Al-Rukban, M. Guidelines for the construction of multiple choice questions tests. J. Fam. Community Med. 2006 , 13 , 125–133. [ Google Scholar ] [ CrossRef ]
• Scott, K.R.; King, A.M.; Estes, M.K.; Conlon, L.W.; Phillips, A.W. Evaluation of an Intervention to Improve Quality of Single-best Answer Multiple-choice Questions. WestJEM 2018 , 20 , 11–14. [ Google Scholar ] [ CrossRef ]
• Stough, L.M. Research on Multiple-Choice Questions: Implications for Strategy Instruction. In Annual Convention of the Council for Exceptional Children , 71st ed.; Council for Exceptional Children: San Antonio, TX, USA, 1993; pp. 1–11. [ Google Scholar ]
• Carneson, J.; Delpierre, G.; Masters, K. Designing and Managing Multiple Choice Questions , 2nd ed.; Cape Town, South Africa, 2016. [ Google Scholar ] [ CrossRef ]
• DiSantis, D.J. A Step-By-Step Approach for Creating Good Multiple-Choice Questions. Can. Assoc. Radiol. J. 2020 , 71 , 131–133. [ Google Scholar ] [ CrossRef ]
• Vuma, S.; Sa, B. A comparison of clinical-scenario (case cluster) versus stand-alone multiple choice questions in a problem-based learning environment in undergraduate medicine. J. Taibah Univ. Med. Sci. 2016 , 12 , 14–26. [ Google Scholar ] [ CrossRef ]
• Stringer, J.K.; Santen, S.A.; Lee, E.; Rawls, M.; Bailey, J.; Richards, A.; Perera, R.A.; Biskobing, D. Examining Bloom’s Taxonomy in Multiple Choice Questions: Students’ Approach to Questions. Med. Sci. Educ. 2021 , 31 , 1311–1317. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Kurdi, G.R. Generation and Mining of Medical, Case-Based Multiple Choice Questions ; The University of Manchester: Manchester, UK, 2020. [ Google Scholar ]
• Zhao, W.; He, L.; Deng, W.; Zhu, J.; Su, A.; Zhang, Y. The effectiveness of the combined problem-based learning (PBL) and case-based learning (CBL) teaching method in the clinical practical teaching of thyroid disease. BMC Med. Educ. 2020 , 20 , 381. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Grainger, R.; Dai, W.; Osborne, E.; Kenwright, D. Medical students create multiple-choice questions for learning in pathology education: A pilot study. BMC Med. Educ. 2018 , 18 , 201. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Rakangor, S.; Ghodasara, D.Y.R. Literature Review of Automatic Question Generation Systems. Int. J. Sci. Res. Publ. 2015 , 5 , 1–5. [ Google Scholar ]
• Zhang, R.; Guo, J.; Chen, L.; Fan, Y.; Cheng, X. A Review on Question Generation from Natural Language Text. ACM Trans. Inf. Syst. 2021 , 40 , 1–43. [ Google Scholar ] [ CrossRef ]
• Rodriguez-Torrealba, R.; Garcia-Lopez, E.; Garcia-Cabot, A. End-to-End generation of Multiple-Choice questions using Text-to-Text transfer Transformer models. Expert. Syst. Appl. 2022 , 208 , 118258. [ Google Scholar ] [ CrossRef ]
• Smith, P.E.; Mucklow, J.C. Writing clinical scenarios for clinical science questions. Clin. Med. 2016 , 16 , 142–145. [ Google Scholar ] [ CrossRef ]
• Salam, A.; Yousuf, R.; Abu Bakar, S.M. Multiple Choice Questions in Medical Education: How to Construct High Quality Questions. Int. J. Hum. Health Sci. IJHHS 2020 , 4 , 79–88. [ Google Scholar ] [ CrossRef ]
• Bowen, J.L. Educational Strategies to Promote Clinical Diagnostic Reasoning. N. Engl. J. Med. 2006 , 355 , 2217–2225. [ Google Scholar ] [ CrossRef ]
• Hattie, J.; Timperley, H. The Power of Feedback. Rev. Educ. Res. 2007 , 77 , 81–112. [ Google Scholar ] [ CrossRef ]
• Biggs, J. Aligning teaching for constructing learning. High. Educ. Acad. 2003 , 1 , 1–4. [ Google Scholar ]
• Hadifar, A.; Bitew, S.K.; Deleu, J.; Develder, C.; Demeester, T. EduQG: A Multi-Format Multiple-Choice Dataset for the Educational Domain. IEEE Access 2023 , 11 , 20885–20896. [ Google Scholar ] [ CrossRef ]
• Messick, S. Validity of psychological assessment: Validation of inferences from persons’ responses and performances as scientific inquiry into score meaning. ETS Res. Rep. Ser. 1994 , 1994 , i-28. [ Google Scholar ] [ CrossRef ]
• Prince, M. Epidemiology. In Core Psychiatry , 3rd ed.; Wright, P., Stern, J., Phelan, M., Eds.; Saunders Ltd. (Elsevier): Philadelphia, PA, USA, 2012; pp. 115–129. [ Google Scholar ] [ CrossRef ]
• Messick, S. Validity of psychological assessment: Validation of inferences from persons’ responses and performances as scientific inquiry into score meaning. Am. Psychol. 1995 , 50 , 741–749. [ Google Scholar ] [ CrossRef ]
• Nunnally, J.C. Psychometric Theory—25 Years Ago and Now. Educational Researcher. Educ. Res. 1975 , 4 , 7–21. [ Google Scholar ] [ CrossRef ]
• Kuder, G.F.; Richardson, M.W. The theory of the estimation of test reliability. Psychometrika 1937 , 2 , 151–160. [ Google Scholar ] [ CrossRef ]
• Tarrant, M.; Knierim, A.; Hayes, S.K.; Ware, J. The frequency of item writing flaws in multiple-choice questions used in high stakes nursing assessments. Nurse Educ. Today 2006 , 26 , 662–671. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Kim, K.H.; Zabelina, D. Cultural bias in assessm ent: Can creativity assessm ent help? Int. J. Crit. Pedagog. 2015 , 6 , 129–146. [ Google Scholar ]
• Cizek, G.J. Cheating on Tests: How to Do It, Detect It, and Prevent It , 1st ed.; Routledge: New York, NY, USA, 1999. [ Google Scholar ] [ CrossRef ]
• Masters, K. A Brief Guide to Understanding MOOCs. Internet J. Med. Educ. 2010 , 1 , 1–6. [ Google Scholar ] [ CrossRef ]
• Larranaga, M.; Aldabe, I.; Arruarte, A.; Elorriaga, J.A.; Maritxalar, M. A Qualitative Case Study on the Validation of Automatically Generated Multiple-Choice Questions from Science Textbooks. IEEE Trans. Learn. Technol. 2022 , 15 , 338–349. [ Google Scholar ] [ CrossRef ]
• Merchant, Z.; Goetz, E.T.; Cifuentes, L.; Keeney-Kennicutt, W.; Davis, T.J. Effectiveness of virtual reality-based instruction on students’ learning outcomes in K-12 and higher education: A meta-analysis. Comput. Educ. 2014 , 70 , 29–40. [ Google Scholar ] [ CrossRef ]
• Williams, J.B.; Wong, A. The efficacy of final examinations: A comparative study of closed-book, invigilated exams and open-book, open-web exams. Br. J. Educ. Technol. 2009 , 40 , 227–236. [ Google Scholar ] [ CrossRef ]
• Chen, B.; Bastedo, K.; Howard, W. Exploring Best Practices for Online STEM Courses: Active Learning, Interaction & Assessment Design. OLJ 2018 , 22 , 59–75. [ Google Scholar ] [ CrossRef ]

Share and Cite

Al Shuriaqi, S.; Aal Abdulsalam, A.; Masters, K. Generation of Medical Case-Based Multiple-Choice Questions. Int. Med. Educ. 2024 , 3 , 12-22. https://doi.org/10.3390/ime3010002

Al Shuriaqi S, Aal Abdulsalam A, Masters K. Generation of Medical Case-Based Multiple-Choice Questions. International Medical Education . 2024; 3(1):12-22. https://doi.org/10.3390/ime3010002

Al Shuriaqi, Somaiya, Abdulrahman Aal Abdulsalam, and Ken Masters. 2024. "Generation of Medical Case-Based Multiple-Choice Questions" International Medical Education 3, no. 1: 12-22. https://doi.org/10.3390/ime3010002

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Case-based multiple-choice questions.

Q .1- A 64-year-old man who develops acute renal failure while recovering from a severe acute myocardial infarction (Acute MI), Blood chemistry reveals:

Na + 140 mEq/L,

K + 4 mEq/L,

Cl – 115 mEq/L,

CO 2 5 mEq/L,

PaCO 2 13 mmHg, and

HCO3 – 4 mEq/L.

Calculate the anion gap and then choose the best answer for acid-base status.

A) His anion gap of 14 indicates he has metabolic alkalosis

B) His anion gap of 20 is conclusive of respiratory acidosis.

C) His anion gap of 22 strongly suggests a respiratory alkalosis

D) His anion gap of 21 is conclusive of high anion gap metabolic acidosis

E) His anion gap of 25 is conclusive of normal acid-base status.

Q.2- A 48-year-old man with bronchiectasis presents to the hospital emergency room with 3 days of increasing cough, sputum, and dyspnea. About 1 month ago, his arterial blood gas analysis showed pH 7.38, PaO 2 55 mmHg, PaCO 2 65 mmHg, and HCO 3 – 32 mEq/L. His current vital signs are BP 117/65 mmHg, Pulse 123/min, Temperature 100°F. His current ABG(Blood gas analysis) in the Emergency Room is pH 7.28, PaCO 2 70 mmHg, PaO 2 50 mmHg, and HCO 3 – 23 mEq/L. Which of the following best characterizes the current acid-base status?

A) Compensated metabolic acidosis

B) Compensated metabolic alkalosis

C) Uncompensated metabolic acidosis

D) Uncompensated respiratory acidosis

E) Uncompensated respiratory alkalosis

Q.3- A hospital patient with AIDS has diarrhea and becomes hypovolemic within a short period of time. Which of the following laboratory results would best fit this clinical history?

A) pH: 7.15, pCO2: 55 mmHg, HCO3: 40 mEq/L

B) pH: 7.25, pCO2: 36 mmHg, HCO3: 15 mEq/L

C) pH: 7.40, pCO2: 40 mmHg, HCO3: 24 mEq/L

D) pH: 7.50, pCO2: 28 mmHg, HCO3: 24 mEq/L

E) pH: 7.35, pCO2: 40 mmHg, HCO3: 24 mEq/L.

Q.4- A 50-year-old chronic alcoholic is brought to the emergency room in a semiconscious state. Blood pressure is 100/50 mmHg, heart rate 120 beats/min, respiratory rate 35/min, and his temperature is 104F (40C).

Blood chemistry reveals : Sodium 150mEq/L (135-145), Potassium 2.5mEq/L (3.5-5.0), Chloride 107mEq/L (95-105),Bicarbonate 10mEq/L (24-26), pH 7.2 (7.35-7.45), PCO2 25mmHg (35-45), Alcohol 40mmol/L (0), Osmolality 370mOsm/L (280-295), Glucose 50mg/dl (60-110) BUN 40mg/dl (5-22). What is the acid-base status?

A) Metabolic acidosis

B) Metabolic Alkalosis

C) Respiratory acidosis

D) Respiratory alkalosis

E) Metabolic acidosis with respiratory compensation

Q.5-All of the following statements are correct about potassium balance, except:

A) Most of the potassium is intracellular.

B) Three-quarters of the total body potassium is found in skeletal muscle.

C) Intracellular potassium is released into extracellular space in response to severe injury.

D) Acidosis leads to the movement of potassium from extracellular to the intracellular fluid compartment.

E) Aldosterone promotes excretion of potassium and reabsorption of sodium.

Q.6- Normal anion gap metabolic acidosis is caused by all except:

B) Starvation

C) Ethylene glycol poisoning.

D) Lactic acidosis

E) Methanol poisoning.

Q.7- Which of the following is more appropriate for a 17-year-old Female suffering from IDDM with the following blood chemistry report:

pH: 7.2,  PO 2 : 108 mm Hg, PCO 2 : 12 mmHg and HCO 3 – : 5 meq/L

A) Metabolic Acidosis with respiratory alkalosis

B) Respiratory Acidosis

C) Metabolic Alkalosis

E) Metabolic alkalosis with respiratory alkalosis

Q.8- A middle-aged person collapsed on the roadside and was brought to an emergency, Blood chemistry revealed the following:

pH- 7.51, PCO 2 – 35 mm Hg, PO2- 62mm Hg and HCO3 – -27 meq/L.

Which of the following is the most appropriate acid-base imbalance in the above-said condition?

B) Metabolic alkalosis with respiratory acidosis

C) Respiratory alkalosis with metabolic compensation

D) Respiratory acidosis

E) Metabolic alkalosis with respiratory alkalosis.

Q.9- A 24 –year female reported to the emergency with difficulty in breathing. History revealed that she had ingested some unknown drug. The blood chemistry revealed the following:

PH-7.1; PCO 2 – 55 mm Hg; PO 2 -42 mm Hg and HCO 3 — 17 meq/L

A) Metabolic acidosis with respiratory acidosis

B) Respiratory acidosis

C) Respiratory Alkalosis

D) Metabolic alkalosis

E) None of the above.

Q.10- Which of the following is incorrect about minimum excretory volume?

A) The exact quantity depends on the concentrating power of the kidney

B) The exact quantity depends on the quantity of the solute load

C) The urinary volume is approximately 500 to 600 ml in 24 hrs

D) It is the minimum volume of urine excreted to eliminate the “waste products” of metabolism.

E) It is the amount of urine excreted per day in normal health.

Q.11- The anion gap is calculated as follows: 

A) [K + ] + [HCO 3 – + Cl – ]

B) [Na + ] + [Cl – + HCO 3 – ] C) [Na + ] – [HCO 3 – + Cl – ]

D) [Na + ] + [K + ]-[C l- + HCO3 – ]

Q.12- ADH release is stimulated by any of the following except:

A) Increased serum osmolality

B) Increased blood volume

C) Decreased Blood pressure

E) Hyponatremia

Q.13- Which of the following is not a cause of pure salt depletion?

A) In mental patients who refuse to drink

B) Excessive sweating

C) Renal failure

D) Mineralocorticoid deficiency

E) Chronic diarrhea

Q.14- Hypokalemia is serum K concentration < 3.5 mEq/L and is caused by:

A) Renal losses

B) GI losses

C) Diuretics

D) Insulin administration

E) All of the above.

Q.15- Hyponatremia is decreased in serum Na concentration < 136 mEq/L and is caused by :

A) Diuretic use

B) Crush injuries

C) Hemolysis

D) High fever

Q.16- Serum sodium concentration is regulated by:

A) Stimulation of thirst,

B) Secretion of ADH,

C) Renin-angiotensin-aldosterone system,

D) Variations in renal handling of filtered sodium

Q.17- Factors that shift Potassium in or out of cells include the following:

A) Blood glucose concentration

B) Blood volume

C) Acid-base status

D) Serum Sodium concentration

Q.18- Which of the following is not a cause of hyperkalemia?

A) Acute renal failure

C) Metabolic acidosis

E) Intake of bananas.

Q.19- The Henderson-Hassel Balch equation is represented as-

A) pH = pKa + log (A – /HA)

B) pH = pKa + log (HA/A – )

C) pH = pKa – log(A – /HA)

D) pH = pKa – log(HA/A – )

E) pH = pKa + log(H + /HA)

Q.20- All are true for renal handling of acids in metabolic alkalosis except

A) Hydrogen ion secretion is decreased

B) Bicarbonate reabsorption is decreased

C) Urinary acidity is decreased

D) Urinary ammonia is decreased

E) Renal Glutaminase activity is increased.

Key to answers

1)- D, 2)- D, 3)-B, 4)- E, 5)-D, 6)-A, 7)- A, 8)-E, 9)-A, 10)-E, 11)-C, 12)- B, 13)-A,14)-E, 15)- A, 16)- E, 17)- E, 18)- D, 19)- A, 20)-E.

• Case based discussions
• Compensated metabolic acidosis
• Compensated metabolic alkalosis
• Henderson-Hassel Balch equation
• high anion gap metabolic acidosis
• Hypokalemia
• Metabolic acidosis with respiratory compensation
• metabolic alkalosis
• renal handling of acids
• respiratory acidosis
• Uncompensated metabolic acidosis
• Uncompensated respiratory acidosis
• Uncompensated respiratory alkalosis

Reference Books By Dr. Namrata Chhabra

Home » Nursing Students » Tips for Answering Next Gen NCLEX® Case Studies

Tips for Answering Next Gen NCLEX® Case Studies

• Last Updated: January 24, 2024

• Next Gen NCLEX

The biggest difference between the “old NCLEX” and Next Gen NCLEX (NGN) is the more precise measurement of your clinical judgment through new unfolding case studies. Every candidate will receive three scored case studies, each with six questions (18 questions total), making case study practice essential to NCLEX prep. We’ll walk you through the ins and outs of this new question style to help you understand what to expect on the NGN and how to achieve a passing score.

Prefer a video? Check out this UWorld NCLEX case study presented by one of our nursing experts:

What Are NGN Case Studies?

Next Gen NCLEX case studies measure a candidate’s clinical judgment by describing a clinical scenario, sharing “unfolding” client information, and asking questions related to Layer 3 of the NCSBN Clinical Judgment Measurement Model (NCJMM). 1 Put another way…

NGN case studies present a realistic patient scenario that you must navigate, step by step, starting with identifying and analyzing relevant client information, then planning and providing treatment, and lastly evaluating client outcomes.

The result is a six-question set that requires you to: 1

This multi-step approach is designed to better assess your entry-level nursing knowledge, skills, and abilities, and differentiate your understanding from that of other candidates by using partial-credit scoring. 2

Components of an NGN Case Study

Instead of simply using traditional multiple-choice questions to test the six sequential NCJMM steps, NGN case studies may use any of the traditional or new Next Gen NCLEX item types (excluding trend and bow-tie questions). These include: 2

You’ll also want to be familiar with the various types of information you will see as case study scenarios unfold and reveal changes in the patient’s status. This often begins with Nurses’ Notes or the client’s medical history, and incorporates other clinical data (like vital signs) in a tabular format that’s updated as the case study unfolds.

NGN case study clinical scenario

NGN case studies start by providing a general overview of a clinical scenario. Just like in real life, you may not have all of the information you need to make a sound clinical decision. In the following example from our NCLEX Review Course, you’re initially provided with Nurses’ Notes and must highlight the five most important client findings:

Remember that questions 1 and 2 in an NGN case study examine your ability to recognize and analyze cues. In this example, it’s not until question 3 that the scenario unfolds further and you’re provided with additional client information.

NGN case study supporting information

The way NGN case studies provide supporting client information varies. Sometimes, you’ll have access to all of the information you need from the beginning. In many cases, additional information will become available as if you were working with an actual patient and gathering clinical details in real-time. Read the new information carefully and answer the associated question as best you can. It’s important to note that on the NCLEX, you cannot go back and answer previous questions . Continuing our above NGN case study example, question 3 is when you gain access to Laboratory Results:

In this step, you’re asked the first of two questions related to refining your hypotheses. From here, this case study progresses through the remaining NCJMM steps, but does not provide any additional client information.

During your exam, client information will always be stored in this tabular format (common tabs are Nurses’ Notes, Vital Signs, History and Physical, Orders, Laboratory Results, Diagnostic Results, etc.). While their names may vary, what’s more important is understanding where relevant information is located so you can successfully answer the questions.

How Are NGN Case Studies Scored?

NGN case studies use partial-credit scoring (polytomous scoring) to differentiate between students who fully understand, partly understand, and don’t understand questions. This new NCLEX scoring method varies by question type, but there are three general rules to know:

• +/- scoring is used for questions that have more than one answer option, but with an unspecified number of correct answers (e.g., SATA, Highlight, and Matrix Multiple Response). Selecting a correct option provides +1 point, while selecting an incorrect option results in -1 point. The lowest possible score for all question types is 0.
• Rationale scoring is used for cause and effect-style questions. When there are two answer options, both must be answered correctly to receive credit. When there are three, partial credit may apply. For example, “A nurse must do X because of Y and Z.” If a student answers X and either Y or Z correctly, they will receive partial credit. 3
• 0/1 scoring is a more familiar scoring method where you either get the question right or wrong (think multiple choice). Each correct option you select provides 1 point, and each incorrect option you select adds 0 points.

NGN partial-credit scoring is more forgiving than traditional NCLEX scoring, which can help ease anxiety in answering case study questions. Even if you misinterpret a scenario and answer the initial questions incorrectly, you still have time to change course. Like with any exam, practicing beforehand is the best way to prepare.

NGN case studies vs stand-alone questions

NGN stand-alone questions are similar to case studies because they also measure your clinical judgment based on Layer 3 of the NCJMM. However, stand-alone questions can use any NGN question type, including trend and bow-tie questions : 4

• Trend questions feature one question apiece, and may include one or more steps from NCJMM Layer 3. This means you’ll need to make one or more clinical decisions per question.
• Bow-tie questions feature one question apiece, but include all six steps from NCJMM Layer 3. This means you’ll need to make multiple clinical decisions all in one question.

How many NGN case studies are on the NCLEX?

Whether you answer the minimum 85 questions, maximum 150 questions, or somewhere in between, three of your case studies (totaling 18 questions) will be scored. It’s important to note that you may receive more case studies (one or two additional) that are being piloted for pretesting and are not scored. Question types may differ, but 18 case study questions will count toward your score. 2

How to Approach NGN Case Studies

Before you begin an NGN case study, remember that you cannot go back after a question is submitted . So make sure you’ve fully answered each question before moving on to the next one. With this in mind, here are some additional NGN case study tips from our nursing team:

Understand the NCSBN’s Clinical Judgment Measurement Model

Getting familiar with the NCJMM may sound like overkill, but it will help you develop your clinical judgment and truly think like a nurse. This is crucial when it comes to successfully answering NGN case studies, where simply memorizing facts isn’t enough to achieve success.

The NCJMM was designed as a thinking and teaching framework, and fully breaks down a nurse’s decision-making process into six measurable steps. These steps form Layer 3 of the NCJMM that NGN case studies test you on. Keeping the full framework in mind as you take the NCLEX will make it easier to recognize the what and why behind each NGN case study question.

Identify the main question in the case study scenario

Just like when caring for a real patient, identifying the condition(s) that your simulated patient is experiencing is the first step in deciding how to provide effective care. Everything else in the case study will build on this initial information. Don’t forget that NGN case studies are written to be as realistic as possible, so some information you receive will likely be irrelevant. This is where your skills in prioritization come into play.

Look for clues in the case study scenario

Figuring out what clinical information matters and what doesn’t requires practice. One trick you can use when reading an NGN case study is to identify keywords that signal something is important (e.g., new, change in, increased/decreased, etc.). You should also consider questions like, “How long have symptoms persisted?” And, “What changes to the body are present?”

Think critically about the supporting information

As a case study unfolds and you’re presented with supporting client information, ask yourself why the new information is relevant to the client’s main condition(s). The best way to go about this is to visualize yourself working with a real patient. Did the lab results we ordered become available? Great! Let’s consider how they impact our hypotheses. Did we receive an update about the patient in the form of new Nurses’ Notes? Interesting. Let’s check to see if our treatment worked as expected.

Carefully follow the directions for each question

The Next Gen NCLEX is unique in that it evaluates students’ performance using a variety of question types. You can’t just assume a question is multiple choice with one correct response. Especially when completing case studies, pay attention to the NGN item type you’re being asked to complete (e.g., Highlight, SATA, Drag and Drop, Matrix, etc.).

Eliminate “distractors” in the answer choices

As you tackle case study questions, eliminate potential distractors (incorrect answer choices). When you work with real patients, you’ll be confronted with irrelevant medical information that may lead you to draw incorrect conclusions. NGN case studies purposely incorporate common clinical judgment errors and allow candidates to pursue incorrect treatment paths. To avoid mistakes, always keep the case study’s main client condition(s) in mind and cross out obvious distractors.

Practice Next Gen NCLEX Case Study Questions

NGN case studies take some time to get used to. At first, half the battle is understanding the item types and how to identify relevant information. But, as the saying goes, practice makes perfect! By practicing NGN case studies before your exam, you can get familiar with the testing layout, develop your clinical judgment, boost your confidence, and maximize your score.

At UWorld Nursing, we offer over 500 NGN questions for RN and 400 NGN questions for PN with over 200  lecture videos to enhance your understanding. While NGN case studies may appear intimidating, they’re nothing you can’t handle with a little practice.

High-yield videos, thousands of practice questions, multiple self-assessment tests, and more.

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Case-based learning and multiple choice questioning methods favored by students

Magalie chéron.

Department for Psychoanalysis and Psychotherapy, Advanced Postgraduate Program for Psychotherapy Research, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria

Mirlinda Ademi

Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria

Felix Kraft

Department of Anaesthesia, General Intensive Care and Pain Therapy, Medical University Vienna, Vienna, Austria

Henriette Löffler-Stastka

Investigating and understanding how students learn on their own is essential to effective teaching, but studies are rarely conducted in this context. A major aim within medical education is to foster procedural knowledge. It is known that case-based questioning exercises drive the learning process, but the way students deal with these exercises is explored little.

This study examined how medical students deal with case-based questioning by evaluating 426 case-related questions created by 79 fourth-year medical students. The subjects covered by the questions, the level of the questions (equivalent to United States Medical Licensing Examination Steps 1 and 2), and the proportion of positively and negatively formulated questions were examined, as well as the number of right and wrong answer choices, in correlation to the formulation of the question.

The evaluated case-based questions’ level matched the United States Medical Licensing Examination Step 1 level. The students were more confident with items aiming on diagnosis, did not reject negatively formulated questions and tended to prefer handling with right content, while keeping wrong content to a minimum.

These results should be taken into consideration for the formulation of case-based questioning exercises in the future and encourage the development of bedside teaching in order to foster the acquisition of associative and procedural knowledge, especially clinical reasoning and therapy-oriented thinking.

Trying to understand how students learn on their own, aside from lectures, is essential to effective teaching. It is known that assessment and case-based questioning drive the learning process. Studies have shown that the way assessment is being conducted influences students’ approach to learning critically [ 1 ]. Several written methods are used for the assessment of medical competence: Multiple Choice Questions (MCQs), Key Feature Questions, Short Answer Questions, Essay Questions and Modified Essay Questions [ 2 ]. Based upon their structure and quality, examination questions can be subdivided into (1) open-ended or multiple choice and (2) context rich or context poor ones [ 3 , 4 ].

Well-formulated MCQs assess cognitive, affective and psychomotoric domains and are preferred over other methods because they ensure objective assessment, minimal effect of the examiner’s bias, comparability and cover a wide range of subjects [ 5 ]. Context rich MCQs encourage complex cognitive clinical thinking, while context poor or context free questions mainly test declarative knowledge (facts, “what” information), which involves pure recall of isolated pieces of information such as definitions or terminologies. In contrast, procedural knowledge (“why” and “how” information) requires different skills: Students are encouraged to understand concepts and to gather information from various disciplines in order to apply their knowledge in a clinically-oriented context. Remarkably, prior clinical experience has been suggested to be a strong factor influencing students’ performance in procedural knowledge tasks [ 6 , 7 ]. With the focus of teaching students to think critically, test items must require students to use a high level of cognitive processing [ 3 ]. A successful approach is using Extended Matching Items (EMIs), consisting of clinical vignettes [ 2 ]. This format is characteristic for examination questions in Step 2 of the United States Medical Licensing Examination (USMLE) [ 8 ]. Step 2 items, test the application of clinical knowledge required by a general physician and encourage examinees to make clinical decision rather than to simply recall isolated facts [ 6 ]. As a well-established examination format introduced by the National Board of Medical Examiners (NBME) USMLE question criteria served for the comparison in our study.

Case-based learning (CBL) has gained in importance within past years. This well-established pedagogical method has been used by the Harvard Business School since 1920 [ 9 ]. Nevertheless, there is no international consensus on its definition. CBL as introduced to students of the Medical University of Vienna (MUV, Austria) in Block 20 is inquiry-based learning demanding students to develop clinical reasoning by solving authentic clinical cases presented as context rich MCQs. Generally, exposing students to complex clinical cases promotes (1) self-directed learning, (2) clinical reasoning, (3) clinical problem-solving and (4) decision making [ 9 ]. In contrast to other testing formats CBL facilitates deeper conceptual understanding. As students see the direct relevance of the information to be learnt, their motivation increases and they are more likely to remember facts. Studies showed that CBL fosters more active and collaborative learners and that students enjoy CBL as a teaching method [ 9 ]. This is in line with the improving results from the students’ evaluation of the course Psychic Functions in Health and Illness and Medical Communication Skills-C ( Block 20/ÄGF-C ) performed in 2013 [ 10 ] and 2014 [ 11 ] at the MUV. A Likert scale ranging from 1 (very bad) to 4 (very good) was used to evaluate the quality of the lectures: The mean grade improved from 1.6 in 2013 to 3 one year later, after the introduction of online case-based exercises related to the lectures. Therefore, based upon the assumption that students tend to prefer practical learning, the development of case-based question driven blended-learning will be further encouraged at the MUV, in order to aim for an effective training for the fostering of procedural knowledge, necessary for clinical reasoning processes and clinical authentic care.

There are no published studies analyzing the way medical students construct MCQs regarding their level of clinical reasoning. To learn more about how students deal with case-based questioning we analyzed student-generated MCQs. The study gives important insights by examining students’ way of reasoning, from formal reasoning using only declarative knowledge to clinical and procedural reasoning based on patients’ cases. Moreover, this study allows to observe to what extent negatively formulated questions, a rarely used format in exams, may not be a problem for students.

This analysis is based on the evaluation of a compensatory exercise for missed seminars completed by students in their fourth year of medical studies at the MUV, after attending their first course on psychic functioning ( Block 20/ÄGF-C ). The 5-week-long Block 20 [ 12 ] focused on the fundamentals of psychic functions, the presentation of the most important psychological schools and on the significance of genetic, biological, gender-related and social factors, as well as on the presentation of psychotherapeutic options and prevention of psychic burden [ 13 ]. Basis of the doctor-patient communication and of psychological exploration techniques were offered [ 12 ]. To pass Block 20 , all students had to take part to the related online CBL [ 14 ] exercise. This exercise presented patients cases including detailed information on diagnosis and therapy, subdivided in psychotherapy and pharmacology. The students had to answer MCQ concerning each diagnostic and therapeutic step.

The current study was approved by the ethics committee of the Medical University of Vienna, students gave informed consent to take part and data is deposited in publicly available repositories (online CBL exercise) after finishing the study. The students were instructed to create MCQs with 4–5 answer possibilities per question, related to cases of patients with psychopathological disorders presented in the online CBL exercise and in the lectures’ textbook of the Block 20 [ 15 ]. The “One-Best Answer” format was recommended. Additionally, the students were required to explain why the answers were right or wrong. MCQ examples were offered to the students in the online CBL exercise.

The authors performed the assessment and classification of the students’ MCQs after group briefings. A final review was done by MC to ensure inter-rater reliability, it was stable at k  = .73 between MC and HLS.

Subjects covered by the questions

The proportions of epidemiology, etiology/pathogenesis, diagnosis and therapy oriented items were examined. In order to simplify the classification, etiology and pathogenesis items were gathered into one group. Items asking for symptoms, classifications (e.g. ICD 10 criteria) as well as necessary questions in the anamnesis were gathered as diagnosis items. Among the therapy items, the frequency of items concerning psychotherapy methods and pharmacology was also compared. The proportion of exercises including at least one diagnosis item and one therapy item was observed. These subjects were chosen according to the patient cases of the CBL exercises and the lectures’ textbook.

Level of the questions

The level of the questions was evaluated in comparison to USMLE equivalent Steps 1 and 2, as described by the NBME. While Step 1 questions (called recall items ) test basic science knowledge, “every item on Step 2 provides a patient vignette” and tests higher skills. Step 2 questions are necessarily application of knowledge items and require interpretation from the student [ 6 ].

To assess the level of the items, 2 further groups were created, distinguishing items from the others. Examples of Step 1 and Step 2 Items’ stems offered by the students:

Step 1: “What is the pharmacological first line therapy of borderline patients?” (Item 31) Step 2: “M. Schlüssel presents himself with several medical reports from 5 specialists for neurology, orthopedics, trauma surgery, neuroradiology and anesthesia, as well as from 4 different general practitioners. Diagnostic findings showed no evidence for any pathology. Which therapy options could help the patient?” (Item 86)

Further, “Elaborate Items” were defined by the authors as well thought-out questions with detailed answer possibilities and/or extensive explanations of the answers.

Finally, “One-Step questions” and “n-steps questions” were differentiated. This categorization reflects the number of cognitive processes needed to answer a question and estimates the complexity of association of a MCQ. Recall items are necessarily one-step questions, whereas application of knowledge items may be one-step questions or multiple (n) steps questions. Because the evaluation of the cognitive processes is dependent on the knowledge of the examinee, the NBME does not give priority to this categorization anymore, although it gives information on the level and quality of the questions [ 6 ]. The previous example of a Step 2 question (Item 86) is an application of knowledge (Step 2) item categorized as n-Step item, because answering the question necessitates an association to the diagnosis, which is not explicitly given by the question. An example for a Step 2 question necessitating only one cognitive process would be: “A patient complains about tremor and excessive sweating. Which anamnestic questions are necessary to ask to diagnose an alcohol withdrawal syndrome?” (Item 232)

Formulation of the questions

The proportion of positively and negatively formulated questions created by the students was examined, as well as the number of right and wrong answer choices, in correlation to the formulation of the question.

Descriptive statistics were performed using SPSS 22.0 to analyze the subjects covered by the questions, their level and formulation, and the number of answer possibilities offered. The significance of the differences was performed using the Chi-square Test or Mann–Whitney U Test, depending on the examined variable, after testing for normal distribution. A given p -value < .05 was considered statistically significant in all calculations.

The study included 105 compensation exercises, performed by 79 students, representing 428 MCQs. After reviewing by the examiner (HLS), who is responsible for pass/fail decisions on the completion and graduation concerning the curriculum element Block 20/ÄGF-C, followed by corrections from the students, two questions were excluded, because the answers offered were not corresponding to the MCQ’s stem. Finally, 426 questions remained and were analyzed.

The subjects covered by the 426 questions concerned the diagnosis of psychiatric diseases (49.1 %), their therapies (29.6 %) and their etiology and pathogenesis (21.4 %). 18 questions covered two subjects (Table  1 ).

Question characteristics: subjects, level and formulation

Significantly more items concerned the diagnosis of psychiatric diseases than their therapies ( p  < .001, Chi-Square Test); 63.3 % of the students offered at least one item regarding diagnosis and one item regarding therapy in their exercise.

Among the therapy items, significantly more pharmacology items were offered than psychotherapy items (59 % versus 41 %; p  = .043, Chi-Square Test).

395 (92.7 %) of the questions were classified as Step 1-questions. Nevertheless, 199 (46.7 %) of the questions were elaborate. 421 (98.8 %) out of the 426 questions were One-Step questions, according to USMLE criteria (Table  1 ). From the 18 questions covering two subjects, 16 were Step 1-questions.

72.5 % of the questions were positively formulated, 27.5 % negatively. A significant difference was observed between the positively and negatively formulated questions regarding the number of right answers: Table  2 shows the distribution of the number of right answers, depending on the questions’ formulation. The students offered significantly more right answer possibilities per positive-formulated question than per negative-formulated questions ( p  < .001, Mann–Whitney U Test).

Questions’ characteristics depending on the questions’ formulation

* p  < 0.001 (Mann–Whitney U Test); SD: Standard deviation; Mean and SD refer to the number of right answers per question and the number of answers per question, respectively, depending on the formulation of the questions; (1) % within formulation groups

The positive-formulated questions had more often two or more right answers than the negative-formulated questions ( p  < .001, Chi-square value = 44.2).

The students also offered less answer possibilities per positive-formulated question than per negative-formulated question ( p  < .001, Mann–Whitney U Test). Further, Table  2 presents the distribution of the number of answers offered depending on the questions’ formulation. The proportion of questions with 4 answer possibilities instead of 5 is higher within the group of positive-formulated questions ( p  < .001, Chi-square value = 16.56). Regarding the proportion of elaborate questions depending on their formulation, there was no significant difference.

Twenty-nine (36.7 %) students offered only positively formulated questions. The students who formulated at least one question negatively (63.3 %) formulated 41.1 ± 22.4 % of their questions negatively.

Many more questions aiming on diagnosis

At the end of year 4, students of the MUV had had various lectures but hardly any actual experiences with therapies. This may explain why significantly more items concerned the diagnosis of psychiatric diseases than their therapies.

Among questions aiming on therapy, significantly more concerned pharmacotherapy than psychotherapy

Before Block 20 , the seminars concerning therapies in the MUV Curriculum were almost exclusively pharmacological. After successful attendance of Block 20 most students who did not have any personal experience of psychotherapy only had little insight into how psychotherapy is developing on the long-term and what psychotherapy can really provide to the patient. Psychotherapy associations were still loaded with old stereotypes [ 13 , 16 ]. This could explain why significantly more therapy questions addressed pharmacology than psychotherapy.

A huge majority of Step 1 questions

The students mainly offered Step 1 questions. It can be questioned, whether the lack of case-oriented questions was an indication for insufficient clinical thinking by the students. An essential explanation could be that students lacked adequate patient contact until the end of year four. Indeed, MUV students were allowed to begin their practical experience after year two and eight compulsory clerkship weeks were scheduled before the beginning of year five [ 17 ]. Thus, Austrian medical students gained consistent clinical experience only after year four, with rotations in year five and the newly introduced Clinical Practical Year in year six. A European comparison of medical universities’ curricula showed that students of other countries spent earlier more time with patients: Dutch, French and German medical students began with a nursing training in year one and had 40, 10 and 4 months, respectively, more clerkship experience than Austrian students before entering year five [ 18 – 21 ]. French and Dutch universities are extremely centered on clinical thinking, with a total of 36 clerkship months in France and the weekly presence of patients from the first lectures on in Groningen [ 22 ]. Thus, it would be interesting to repeat a similar case-based exercise in these countries to explore if medical students at the same educational stage but with more practical experience are more likely to offer patient vignette items.

Students preferred to work with right facts and did not reject negatively worded questions

As negatively worded questions were usually banished from MCQ exams, it was interesting to observe that medical students did not reject them. In fact, negatively formulated questions are more likely to be misunderstood. Their understanding correlates to reading ability [ 23 ] and concentration. Although many guidelines [ 6 , 24 ] clearly advised to avoid negative items, the students generated 27.5 % of negatively formulated questions. Also Pick N format -questions with several right answers were offered by the students, despite the recommendations for this exercise: They offered significantly less total answer possibilities but significantly more right answers to positively worded questions than to negatively worded questions. Those results supported the hypothesis that the students preferred handling right content while keeping wrong content to a minimum.

Several possible reasons can be contemplated. When students lack confidence with a theme and try to avoid unsuitable answer possibilities, it can be more difficult to find four wrong answers to a positively worded question instead of several right answers, which may be listed in a book. Furthermore, some students may fear to think up wrong facts to avoid learning wrong content. Indeed, among positively worded items, 26.6 % were offered with 3 or more right answers, which never happened for negatively worded items (Table  2 ).

Notably, “right answer possibilities” of negatively worded items’ stems as well as “wrong answer possibilities” of positively worded items’ stems are actually “wrong facts”. For example, the right answer of the item “Which of the following symptoms does NOT belong to ICD-10 criteria of depression?” (Item 177) is the only “wrong fact” of the 5 answer possibilities. Writing the 4 “wrong answers” of this question, which are actually the ICD-10 criteria for depression, can help the students learn these diagnostic criteria. On the contrary, the “right answers” to a positively worded item such as “Which vegetative symptoms are related to panic attacks?” (Item 121) are the true facts.

Finally, the students’ interest for right facts supports the theory that a positive approach, positive emotions and curiosity are favorable to learning processes. Indeed, asking for right content is a natural way of learning, already used by children from the very early age. The inborn curiosity — urge to explain the unexpected [ 25 ], need to resolve uncertainty [ 26 ] or urge to know more [ 27 ]— is shown by the amount of questions asked by children [ 28 , 29 ]. The students’ way to ask for right contents appears very close to this original learning process.

The inputs of developmental psychology, cognitive psychology as well as of neurosciences underline this hypothesis. Bower presented influences of affect on cognitive processes: He showed a powerful effect of people’s mood on their free associations to neutral words and better learning abilities regarding incidents congruent with their mood [ 30 ]. Growing neurophysiological knowledge confirmed the close relation between concentration, learning and emotions — basic psychic functions necessitating the same brain structures. The amygdala, connected to major limbic structures (e.g. pre-frontal cortex, hippocampus, ventral striatum), plays a major role in affect regulation as well as in learning processes [ 15 ], and the hippocampus, essential to explicit learning, is highly influenced by stress, presenting one of the highest concentrations of glucocorticoid receptors in the brain [ 31 ]. Stress diminishes the synaptic plasticity within the hippocampus [ 32 ], plasticity which is necessary to long-term memory.

Neuroscientific research also underlined the interdependence of cognitive ability and affect regulation. Salas showed on a patient after an ischemic stroke event with prefrontal cortex damage that, due to executive impairment and increased emotional reactivity, cognitive resources could not allow self-modulation and reappraising of negative affects anymore [ 33 ].

Considering this interdependence, right contents might be related to a positive attitude and positive affects among the students. It could be interesting to further research on this relation as well as on the students’ motivations concerning the formulation of the questions.

The combination of those reasons probably explains why the students offered significantly more wrong answers to negatively worded items and more right answers to positively worded items, both resulting in the use of more right facts. All the students’ assessment questions and associated feedback were used to create a new database at the MUV trying to integrate more right facts in case-based learning exercises in the future.

The main limitation concerns the small sample size and the focus on only one curriculum element. Further studies with convenient sampling should include other medical fields and bridge the gap to learning outcome research.

The evaluation of the questions offered by medical students in their fourth year at the MUV showed that the students were much more confident with items aiming on diagnosis. Among items aiming on therapy, they proved to be more confident with pharmacotherapy than with psychotherapy. These results, together with the improving evaluation of the Block 20 after introducing CBL exercises and the international awareness that case-based questioning have a positive steering effect on the learning process and foster the acquisition of associative and procedural knowledge, should encourage the further development of affective positively involving case-based exercises, especially with a focus on clinical reasoning and therapy-oriented thinking.

The development of bedside teaching and the implementation of clerkships from the first year of studies (e.g. a 4-week practical nursing training) could also be considered in order to stimulate earlier patient-centered thinking of the students of the MUV. A comparison with the level of clinical reasoning of medical students from countries where more practical experience is scheduled during the first year of study would be interesting.

Concerning assessment methods and particularly the formulation of case-based questions, the students did not reject negatively formulated questions, but showed a tendency to prefer working with right contents, while keeping wrong content to a minimum. This preference could be further explored and considered in the future for the formulation of MCQs in case-based exercises.

Availability of supporting data

Data of the patients’ cases, on which the MCQs created by the students were based on, can be found in the textbook of the curriculum element and lectures [ 15 ] and via the Moodle website of the Medical University of Vienna [ 34 ]. The Moodle website is available for students and teachers of the Medical University of Vienna with their username and password. The analyzed and anonymous datasets including the MCQs [ 34 ] are accessible on request directly from the authors.

Acknowledgment

Prof. Dr. Michel Slama.

Abbreviations

Competing interest

The authors declare that they have no competing interests.

The authors declare that they have no financial competing interests.

The authors declare that they have no non-financial competing interest.

Authors’ contribution

MC carried out the study, performed the statistical analysis and drafted the manuscript. MA performed the statistical analysis and helped to draft the manuscript. FK participated in the design of the study and statistical analysis. HLS conceived of the study, participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.

Contributor Information

Magalie Chéron, Email: rf.oohay@norehceilagam .

Mirlinda Ademi, Email: ta.ca.waeo.mmec@imedam .

Felix Kraft, Email: [email protected] .

Henriette Löffler-Stastka, Phone: 0043-1-40400-30700, Email: [email protected] .

NCLEX Practice Questions Test Bank for Free

Welcome to our collection of free NCLEX practice questions to help you achieve success on your NCLEX- RN exam! This updated guide for 2024 includes 1,000+ practice questions, a primer on the NCLEX-RN exam, frequently asked questions about the NCLEX, question types, the NCLEX-RN test plan, and test-taking tips and strategies.

Table of Contents

Nclex-rn practice questions test bank, what is nclex.

• What is Next Generation NCLEX (NGN)? 

Safe and Effective Care Environment

• Health Promotion and Maintenance 
• Psychosocial Integrity 

Physiological Integrity

Clinical judgment, integrated processes, item writers for nclex, computer adaptive test (cat), 95% confidence interval rule, maximum-length exam, run-out-of-time (r.o.o.t.) rule, zero/one (0/1) scoring, plus/minus (+/-) scoring, rationale scoring, pretest items, testing time, unfolding case study, stand-alone items, multiple response select all that apply.

• Multiple Response Select N 

Multiple Response Grouping

• Highlight in Text 

Highlight in Table

Matrix multiple response, matrix multiple choice.

• Drag and Drop Cloze 

Drag and Drop Rationale

Drop down cloze, drop down rationale, drop down in table, chart or exhibit questions, graphic option, select all that apply or multiple-response, fill-in-the-blank, ordered-response, how to register for the nclex, nclex-rn resources, want more practice questions, recommended resources.

Looking for the complete collection of practice questions? For more NCLEX practice questions, please visit our Nursing Test Bank here .

We have included more than 1,000+ NCLEX practice questions covering different nursing topics for this nursing test bank ! We’ve made a significant effort to provide you with the most challenging questions along with insightful rationales for each question to reinforce learning .

We recommend you do all practice questions before you take the actual exam. Doing so will help reduce your test anxiety and help identify nursing topics you need to review. To make the most of the practice exams, try to minimize mistakes to less than 15 questions and take your time answering the questions, especially when reading the rationales.

Quiz Guidelines

Before you start, here are some examination guidelines and reminders you must read:

• Practice Exams : Engage with our Practice Exams to hone your skills in a supportive, low-pressure environment. These exams provide immediate feedback and explanations, helping you grasp core concepts, identify improvement areas, and build confidence in your knowledge and abilities.
• You’re given 2 minutes per item.
• For Challenge Exams, click on the “Start Quiz” button to start the quiz.
• Complete the quiz : Ensure that you answer the entire quiz. Only after you’ve answered every item will the score and rationales be shown.
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Included NCLEX-RN question sets for this nursing test bank are as follows. Please click on the links below and you’ll be redirected to the quiz page:

NEW UPDATE: Introducing Challenge Exams and Practice Exams

Engage with these new modes to enhance your learning journey, each tailored to meet different needs and propel you towards academic achievement.

• Dive into Practice Exam Mode for a supportive learning experience. Here, real-time feedback aids in understanding core concepts and building confidence. It’s your space for growth and preparation.
• Step up to Challenge Exam Mode to test your mastery. With rigorous questions, a leaderboard, and a timer, it’s designed to assess your readiness and foster a competitive spirit.

Test your mastery with these Challenge Exams :

Build your confidence and grasp core concepts with these Practice Exams :

The National Council Licensing Examination (NCLEX) is a comprehensive test administered by the National Council of State Boards of Nursing (NCSBN). It assesses whether candidates possess the necessary knowledge and skills to provide safe and effective nursing care at the entry level. The NCLEX is available in two versions: the NCLEX-RN for registered nurses and the NCLEX-PN for practical/vocational nurses.

The NCSBN, composed of nursing regulatory bodies from all 50 states in the US, the District of Columbia, and four US territories, is responsible for safeguarding the public by ensuring safe nursing care. It sets the standards and guidelines for nursing licensure and develops the NCLEX examinations.

Becoming a registered nurse (RN) requires meeting specific licensure requirements determined by the licensing authorities in each jurisdiction governed by the NCSBN. One of these requirements is passing the NCLEX-RN, which evaluates the competencies necessary for practicing safely and effectively as an entry-level RN. The NCLEX-RN is used by member boards of nursing and many Canadian nursing regulatory bodies to inform their licensure decisions.

What is Next Generation NCLEX (NGN)?

The Next Generation NCLEX (NGN) is currently in effect this April 2023 for RN and LPN / LVN candidates. The change in the NCLEX is driven by the need to adapt to the increasing complexity of client care, advancements in healthcare practice, and the demand for safe clinical decision-making . The NGN aims to address the declining ability of new nursing graduates to make safe clinical decisions by integrating clinical judgment as a key competency. The NGN test format will remain adaptive but with fewer test items. Candidates will encounter Unfolding Case Studies and Stand-Alone Items , scored using partial credit with three different scoring rules. These changes in the NGN aim to assess critical thinking and the ability to make safe clinical judgments during various phases of client care.

In summary, the following are the key changes between the previous NCLEX format and the Next Generation NCLEX (NGN): 

• Same adaptive test format but reduced number of items. The Next Generation NCLEX (NGN) will retain the adaptive test format, similar to the current NCLEX, but with fewer test items. Candidates will answer between 85 and 150 items, with 15 as pretest or unscored items. 
• Case studies. All candidates will encounter three (3) Unfolding Case Studies, each consisting of six test items (a total of 18 items). Clinical situation information will be presented to candidates in a medical record format resembling a table-like structure. These situations are designed to assess their ability to think critically and make safe clinical decisions across different phases of client care. In addition to the case studies, some candidates may have Stand-Alone Items for their NGN exam.
• New NGN item types. The NGN exam will feature new item types, which include questions in unfolding cases and stand-alone items, highlight, cloze, matrix, bow-tie, drag and drop, and extended multiple responses. 
• Scoring differences. NGN test items will be scored differently compared to the current NCLEX. They will utilize partial credit scoring with three different scoring rules: the 0/1 scoring rule, the +/- scoring rule, and the rationale scoring rule. These are explained further below. 

NCLEX-RN Test Plan

The NCLEX test plan is a content guideline to determine the distribution of test questions. NCSBN uses the “Client Needs” categories to ensure the NCLEX covers a full spectrum of nursing activities. It is a summary of the content and scope of the NCLEX to serve as a guide for candidates preparing for the exam and to direct item writers in the development of items.  Additionally, to assess the knowledge, skills, abilities, and clinical judgment necessary for entry-level nursing practice , the NCLEX-RN Test Plan utilizes Bloom’s taxonomy for the cognitive domain. This taxonomy provides a foundation for writing and coding examination items, focusing on application-level or higher-level cognitive abilities that require advanced thought processing.

The content of the NCLEX-RN is organized into four major Client Needs categories: Safe and Effective Care Environment, Health Promotion and Maintenance, Psychosocial Integrity, and Physiological Integrity. Some of these categories are divided further into subcategories. Below is the NCLEX-RN test plan effective as of April 2023 until March 2026: 

There are two subcategories under Safe and Effective Care Environment.

• Management of Care category includes content that tests the nurse ‘s knowledge and ability to direct nursing care that enhances the care delivery setting to protect clients, significant others, and healthcare personnel. 
• Safety and Infection Control category includes content that tests the nurse’s ability required to protect clients, families, and healthcare personnel from health and environmental hazards. 

Health Promotion and Maintenance

Health Promotion and Maintenance category includes content that tests the nurse’s ability to provide and direct nursing care to the client that incorporates knowledge of expected growth and development, preventing and early detection of health problems, and strategies to achieve optimal health. 

Psychosocial Integrity

The Psychosocial Integrity category is content related to the promotion and support for the emotional, mental, and social well-being of the client experiencing stressful events and clients with acute or chronic mental illness . 

In the Physiological Integrity category are items that test the nurse’s ability to promote physical health and wellness by providing care and comfort , reducing risk potential, and managing health alterations. There are four subcategories under Physiological Integrity. 

• Basic Care and Comfort are content to test the nurse’s ability to provide comfort and assistance to the client in performing activities of daily living . 
• Pharmacological and Parenteral Therapies category includes content to test the nurse’s ability to administer medications and parenteral therapies ( IV therapy , blood administration, and blood products). 
• Reduction of Risk Potential category includes content to test the nurse’s ability to prevent complications or health problems related to the client’s condition or prescribed treatments or procedures. 
• Physiological Adaptation category includes questions that test the nurse’s ability to provide care to clients with acute, chronic, or life-threatening conditions. 

Clinical judgment is a central component of the NCLEX-RN Test Plan, reflecting the evolving demands and complexity of nursing practice . Nurses must engage in an iterative, multi-step process that utilizes nursing knowledge to observe and assess situations, identify client concerns, and generate evidence-based solutions to ensure safe client care. Clinical judgment questions are represented through Unfolding Case Studies or individual Stand-Alone Items , with case studies addressing each step of clinical judgment. The following are the six clinical judgment cognitive skills: 

• Recognize cues “What matters most?” Identifying relevant and important information from various sources, such as medical history , laboratory studies, and vital signs.
• Analyze cues “What could it mean?” Organizing and connecting recognized cues to the client’s clinical presentation.
• Prioritize hypotheses “Where do I start?”   Evaluating and prioritizing hypotheses based on urgency, likelihood, risk, difficulty, time constraints, and other factors.
• Generate solutions “What can I do?” Identifying expected outcomes and using hypotheses to define a set of interventions aligned with the expected outcomes.
• Take action “What will I do?” Implementing the highest-priority solution(s) identified.
• Evaluate outcomes “Did it help?” Comparing observed outcomes to expected outcomes to assess the effectiveness of interventions.

Additionally, In contrast to the nursing process or ADPIE , the NCSBN focuses on AAPIE ( assessment , analysis, planning , intervention, evaluation ), wherein nursing diagnosis is not tested at the current NGN because it is not considered a universal language used in health care or the nursing profession. In nursing practice and for the NGN, students must use their pathophysiology knowledge to analyze client assessments and connect them with common conditions in healthcare settings. 

Integral to nursing practice, several processes are integrated throughout the Client Needs categories and subcategories:

• Caring. In an atmosphere of mutual respect and trust, nurses interact with clients, providing encouragement, hope, support, and compassion to help achieve desired outcomes .
• Clinical Judgment . An observed outcome of critical thinking and decision-making , clinical judgment (discussed above) is a dynamic and iterative process. It involves using nursing knowledge to observe and assess situations, prioritize client concerns, generate evidence-based solutions, and deliver safe client care.
• Communication and Documentation . Verbal and nonverbal interactions between nurses, clients, significant others, and the healthcare team. Accurate and comprehensive documentation ensures adherence to practice standards and accountability in care provision.
• Culture and Spirituality. Recognizing and considering the unique preferences, standards of care, and legal considerations of clients (individuals, families, groups, and populations) in the context of their culture and spirituality.
• Nursing Process. A systematic approach to client care encompassing assessment , analysis, planning, implementation , and evaluation .
• Teaching/Learning. Facilitating acquiring knowledge, skills, and abilities that promote behavioral change.

Who writes questions for the NCLEX? The NCSBN sets the criteria and selection process for item writers who are registered nurses. Many of them are nursing educators with an advanced degrees in nursing, so if you’ve completed an accredited nursing program, you have already taken several tests written by nurses with backgrounds similar to those who write for the NCLEX.

The NCLEX-RN is a crucial step for registered nurse (RN) candidates seeking licensure. Administered through computerized adaptive testing ( CAT ), this examination utilizes computer technology and measurement theory to create a personalized and accurate assessment of each candidate’s knowledge and skills. 

The CAT system employed in the NCLEX-RN ensures that each candidate receives a unique examination tailored to their abilities. As the test progresses, the computer selects items from a large item pool based on the candidate’s previous answers. These items are classified according to the test plan categories, difficulty levels, and clinical judgment steps. The CAT system continually recalculates the candidate’s ability estimate and selects subsequent items accordingly, creating an exam that aligns with the NCLEX-RN Test Plan requirements. This dynamic approach allows candidates to demonstrate their competence effectively.

Additionally, unlike traditional fixed-length exams, which assign the same items to all candidates, CAT selects items based on the candidate’s ability, resulting in a more accurate assessment. The CAT scoring algorithm estimates the candidate’s ability by considering all previous answers and the difficulty level of those items. By administering items that challenge the candidate appropriately, the exam gathers maximum information about their ability.

Pass or Fail Decisions: How to Pass the NCLEX?

Passing the NCLEX-RN requires you, the candidate, to meet a specific passing standard established by the NCSBN Board of Directors (BOD). The passing standard represents the minimum ability level necessary for safe and effective entry-level nursing practice. The BOD reevaluates this standard every three years, considering various factors such as a standard-setting exercise conducted by experts and psychometricians, historical data on candidate performance, and information on the educational readiness of aspiring nurses. Once the passing standard is set, it is uniformly applied to all candidates during the scoring process. The NCSBN indicates that these three rules govern pass-or-fail decisions: the 95% Confidence Interval Rule , Maximum-Length Exam Rule , and Run-Out-Of-Time Rule .

In this scenario, the computer stops administering test questions when it is 95% certain that your ability is clearly above the passing standard or clearly below the passing standard. 

When your ability is close to the passing standard, the CAT gives you items until the maximum number of items is reached. At this point, the computer disregards the 95% confidence rule and decides whether you pass or fail by your final ability estimate. If your final ability estimate is above the passing standard, you pass; if it is below, you fail. 

In the event that a candidate runs out of time before completing the maximum number of items and the computer has not reached a 95% certainty regarding the candidate’s pass or fail status, alternative criteria come into play.

• If the candidate has not answered the minimum required number of items, the candidate will automatically fail.
• If the candidate has answered at least the minimum required number of items, the final ability estimate will be determined based on all the responses given before the exam time expires. If the score meets or exceeds the passing standard, the candidate will pass. Otherwise, the candidate will fail.

New Scoring System in the Next Generation NCLEX

The Next Generation NCLEX (NGN) incorporates different item formats, and for items that have multiple correct answers, partial credit scoring is implemented . Unlike the previous exam format, where items are scored as either all correct or all incorrect, the NGN will use polytomous scoring models to evaluate partial understanding. For example, in the previous version of NCLEX (multiple response) SATA (select-all-that-apply) items, only endorsing all the correct options results in a correct score. However, the new approach will acknowledge partial understanding, allowing differentiation between candidates with different numbers of correct options. This change will provide a more accurate assessment of candidates’ knowledge, skills, and abilities.

Three methods are used to assign partial credit for these items: plus/minus scoring, zero/one scoring, and rationale scoring. Understanding the scoring models is crucial for NCLEX-RN takers to know how their answers are evaluated and how scores are determined.

The 0/1 scoring rule is used for multiple-choice items. Choosing the correct option earns one point while selecting an incorrect option gives a score of zero. This rule applies to single response items, including the example multiple-choice item.

The +/– scoring rule measures a candidate’s ability to identify relevant information. It assigns points for correct options and deducts points for incorrect options. It is used for multi-point items, and the total score is calculated by adding correct options and subtracting incorrect ones. The lowest possible score is zero. This rule is applied to NGN question types such as multiple-response and select all that apply.

The rationale scoring rule is used for questions that assess paired information. To earn a score of one point, both answer options must be correct. If either option is incorrect, the score is 0.

How Many Questions Are on the NCLEX?

All RN candidates must answer a minimum of 85 items , while a maximum of 150 items be administered during the five-hour time allotment. Each NCLEX-RN exam includes 15 pretest items (unscored), which are indistinguishable from operational (scored) items.

To ensure the effectiveness of computerized adaptive testing (CAT) in the NCLEX, the difficulty level of each item needs to be determined beforehand. This is achieved by administering these items as pretest items to a large group of NCLEX candidates. Since the difficulty of pretest items is initially unknown, they are not part of your score and are not considered when evaluating a candidate’s ability or determining pass-fail outcomes. Once a sufficient number of responses are collected, the pretest items undergo statistical analysis and calibration. If they meet the required NCLEX statistical standards, they can be used as operational items in future exams. Therefore, candidates must approach every item with their best effort, regardless of whether it is a pretest or an operational item.

The length of the NCLEX-RN examination varies for each candidate based on their responses, but there is a five-hour time limit for the exam, including all breaks. To ensure completion within the allotted time, candidates must maintain a reasonable pace, spending approximately one to two minutes per item . It’s important to note that the length of the examination does not determine pass or fail outcomes; candidates can succeed or fail regardless of the examination’s duration.

Case Studies in NGN

The Next Generation NCLEX (NGN) has introduced case studies that present practical clinical scenarios and include test items aligned with six cognitive abilities of the clinical judgment model. The scenario can occur in various settings, and the client’s outcome can vary, including improvement, stability, or decline with complications. Laboratory results, if included, are presented in a table, and abnormal values are highlighted with an “L” or “H”. There are two types of case studies: Unfolding Case Study with six test items assessing specific skills and Stand-Alone Items with a single test item independent of a case study.

An Unfolding Case Study presents a realistic client situation with evolving data resembling a medical record. It includes multiple phases over time, reflecting changes in the client’s condition. The case study evaluates all six cognitive skills of the clinical judgment model through six questions. Each test-taker receives three (3) unfolding case studies, totaling 18 items across those cases. 

Stand-Alone Items are case studies with a single question, with the item presented as a bow-tie or a trend question type. Candidates who take more than the minimum number of items on the NCLEX receive around six to seven stand-alone cases. 

Question Types in the NCLEX-RN

The different question types for the NCLEX-RN include the following: 

Extended Multiple Response

In Extended Multiple Response item types, test-takers can choose one or more options in Multiple Response Select All That Apply, select a specific number of items in Multiple Response Select N, or choose options from different groupings presented in a table in Multiple Response Grouping, with scoring rules based on the selected type. Extended multiple response may include the following formats:

The Multiple Response Select All That Apply item type allows test-takers to choose one or more answer options. It uses the +/- Scoring Rule, where selecting correct information earns points (+1), and selecting incorrect information results in points deducted (-1). The maximum points achievable are equal to the number of correct options, and the minimum score is 0, with no negative scores. The item must have a minimum of five options and can have up to ten options, with the possibility of all ten options being correct.

Multiple Response Select N

The Multiple Response Select N item type informs the test-taker about the specific number of items (N) that can be selected. The question provides a range of options, with a minimum of five and a maximum of ten options. It uses the 0/1 Scoring Rule, where each correct response earns 1 point, while any incorrect response results in 0 points.

The Multiple Response Grouping utilizes a table to present options, with a minimum of two and a maximum of five groupings. Each grouping consists of a minimum of two and a maximum of four options, ensuring an equal number of options within each grouping. Test-takers are required to select at least one option from each grouping. The item follows the +/- Scoring Rule, meaning there is no negative score per grouping. The total score for the item is determined by summing the points earned within each grouping. The maximum score achievable equals the number of keys (N).

For this NGN item type, the test-taker is presented with information and must highlight specific parts of the information provided.  Highlight question type include the following formats:

Highlight in Text

It involves a paragraph of information where the test-taker must select (highlight) specific parts of the text based on the question’s requirements. The item can include a maximum of ten options for selection and uses the +/- Scoring Rule. 

The Highlight in Table item type involves a table of information. The candidate is tasked with selecting (highlighting) specific parts of the text within the table based on the question’s prompt. The item can include a maximum of ten options for selection. The table has two columns, including a header, and can have up to five rows. This item type uses the +/- Scoring Rule. 

Matrix/Grid

In the Matrix NGN item type, test-takers are presented with a grid-like structure to which they must respond. There are two variations: Matrix Multiple Response, where each column can have multiple correct responses, and Matrix Multiple Choice, where test-takers select one answer option per row. Extended multiple response may include the following formats:

The Matrix Multiple Response item type consists of response columns, where each column can have multiple correct responses. The item can have between two and ten columns and four to seven rows. In each column, at least one response option must be selected, but it is possible to select one or more responses per column. The item follows the +/- Scoring Rule, with no negative score per column. The total score for the item is determined by summing the points earned within each column. The maximum score achievable is equal to the number of keys (N).

The item includes a minimum of four rows and a maximum of ten rows. It can have either two or three options/columns. Test-takers are allowed to select one answer option per row. The item follows the 0/1 scoring rule, where the test-taker earns 1 point for each correct response and 0 points for incorrect responses. The total score for the item is obtained by summing the scores over the rows. The maximum score achievable is equal to the number of rows.

Drag and Drop

In the Drag and Drop NGN question type, test-takers are presented with options to drag and drop into specific targets. There are two variations: Drag and Drop Cloze, where options are placed in response targets to complete sentences and Drag and Drop Rationale, where options are matched to causes and effects. Drag and drop may include the following formats:

Drag and Drop Cloze

The Drag and Drop Cloze item type includes a range of four to ten options. It can have one or more response targets where the options are dragged to. The item must have a minimum of one sentence with one target per sentence and up to five sentences, each with one target per sentence. The item follows the 0/1 Scoring Rule, where a correct response earns 1 point and incorrect responses earn 0 points. The total score is obtained by summing the scores across all targets, with the maximum score achievable being the number of targets.

The Drag and Drop Rationale type involves one sentence with one cause and one effect or one sentence with one cause and two effects. The sentence can be a single dyad (one sentence with two targets) or a single triad (one sentence with three targets). Each drag & drop target can have three to five options. The item follows the Rationale Scoring Rule where both answer options must be correct to earn a point. 

The Drop Down question type in NGN includes three variations: Drop Down Cloze, Drop Down Rationale, and Drop Down in Table. Drop down may include the following formats:

The Drop Down Cloze item type presents one or two sentences of information that require completion using drop-down options. Each drop-down can contain three to five options. The item must have a minimum of one sentence with one drop-down per sentence and can include up to five sentences, each with one drop-down. The item follows the 0/1 Scoring Rule, where the score is calculated by summing the correct responses across all drop-downs. The maximum score achievable is equal to the number of drop-downs.

The Drop Down Rationale item type presents either one sentence with one cause and one effect or one sentence with one cause and two effects. Each drop-down can contain three to five options. The scoring follows the Rationale Scoring Rule, where X and Y must be correct to earn one point. The maximum points that can be earned are 1 point for a dyad (one sentence with two targets) and 2 points for a triad (one sentence with three targets).

The Drop Down in Table item type presents a table of information with drop-down options located in various parts of the table. The item must have a minimum of three columns and three rows and a maximum of five columns and four rows. One column serves as the header column. Each row contains one drop-down. The item follows the 0/1 Scoring Rule, where the score is calculated by summing the correct responses across all drop-downs. The maximum score achievable is equal to the number of drop-downs.

The Bow-tie item type is visually designed to resemble a bow-tie shape. It consists of five options on the left side, five options on the right side, and four options in the middle well of the bow-tie. The item addresses all of the cognitive skills within a single item. The Bow-tie item follows the 0/1 scoring rule. The left and right wells have two answer options each, while the middle well has one answer option, resulting in a maximum possible score of 5 points. Each correct response earns 1 point, while incorrect responses earn 0 points.

The Trend item type presents information in a medical record or flow sheet format that spans over time, requiring the test-taker to analyze information across different points in time. The item addresses multiple cognitive skills within a single item. It can utilize any NGN item type except for the bow-tie. The scoring rule for the Trend item depends on the specific item type used.

Multiple-Choice Questions

Many questions on the NCLEX are in multiple-choice format. This traditional text-based question will provide you data about the client’s situation, and you can only select one correct answer from the given four options. Multiple-choice questions may vary and include: audio clips, graphics, exhibits, or charts.

A chart or exhibit is presented along with a problem. You’ll be provided with three tabs or buttons that you need to click to obtain the information needed to answer the question. Select the correct choice among four multiple-choice answer options. 

In this format, four multiple-choice answer options are pictures rather than text. Each option is preceded by a circle that you need to click to represent your answer.

In an audio question format, you’ll be required to listen to a sound to answer the question. You’ll need to use the headset provided and click on the sound icon for it to play. You’ll be able to listen to the sound as many times as necessary. Choose the correct choice from among four multiple-choice answer options. 

For the video question format, you must view an animation or a video clip to answer the following question. Select the correct choice among four multiple-choice answer options. 

Multiple-response or select all that apply (SATA) alternate format question requires you to choose all correct answer options that relate to the information asked by the question. There are usually more than four possible answer options. No partial credit is given in scoring these items (i.e., selecting only 3 out of the 5 correct choices), so you must select all correct answers for the item to be counted as correct. 

Tips when answering Select All That Apply Questions

• You’ll know it’s a multiple-response or SATA question because you’ll explicitly be instructed to “Select all that apply.”
• Treat each answer choice as a True or False by rewording the question and proceed to answer each option by responding with a “yes” or “no”. Go down the list of answer options one by one and ask yourself if it’s a correct answer.
• Consider each choice as a possible answer separate to other choices. Never group or assume they are linked together.

The fill-in-the-blank question format is usually used for medication calculation, IV flow rate calculation, or determining the intake-output of a client. You’ll be asked to perform a calculation in this question format and type in your answer in the blank space provided. 

Tips when answering Fill-in-the-Blank

• Always follow the specific directions as noted on the screen. 
• There will be an on-screen calculator on the computer for you to use. 
• Do not put any words, units of measurements, commas, or spaces with your answer, type only the number. Only the number goes into the box.
• Rounding an answer should be done at the end of the calculation or as what the question specified, and if necessary, type in the decimal point. 

In an ordered-response question format, you’ll be asked to use the computer mouse to drag and drop your nursing actions in order or priority. Based on the information presented, determine what you’ll do first, second, third, and so forth. Directions are provided with the question. 

Tips when answering Ordered-Response questions

• Questions are usually about nursing procedures. Imagine yourself performing the procedure to help you answer these questions.
• You’ll have to place the options in correct order by clicking an option and dragging it on the box on the right. You can rearrange them before you hit submit for your final answer.

A picture or graphic will be presented along with a question. This could contain a chart, a table, or an illustration where you’ll be asked to point or click on a specific area. Figures may also appear along with a multiple-choice question. Be as precise as possible when marking the location. 

Tips when answering Hotspot questions

• Mostly used to evaluate your knowledge of anatomy, physiology, and pathophysiology.
• Locate anatomical landmarks to help you select the location needed by the item.

So you’ve finally decided to take the NCLEX, the next step is registration or application for the exam. The following are the steps on how to register for the NCLEX, including some tips:

• Application to the Nursing Regulatory Board (NRB). The initial step in the registration process is to submit your application to the state board of nursing in the state in which you intend to obtain licensure. Inquire with your board of nursing regarding the specific registration process as requirements may vary from state to state.
• Registration with Pearson VUE. Once you have received the confirmation from the board of nursing that you have met all of their state requirements, proceed, register, and pay the fee to take the NCLEX with Pearson VUE . Follow the registration instructions and complete the forms precisely and accurately.
• Authorization to Test. If you were made eligible by the licensure board, you will receive an Authorization to Test (ATT) form from Pearson VUE. You must test within the validity dates (an average of 90 days) on the ATT. There are no extensions or you’ll have to register and pay the fee again. Your ATT contains critical information like your test authorization number, validity date, and candidate identification number.
• Schedule your Exam Appointment. The next step is to schedule a testing date, time, and location at Pearson VUE. The NCLEX will take place at a testing center , you can make an exam appointment online or by telephone. You will receive a confirmation via email of your appointment with the date and time you choose including the directions to the testing center. * Changing Your Exam Appointment. You can change your appointment to test via Pearson VUE or by calling the candidate services. Rules for scheduling , rescheduling, and unscheduling are explained further here . Failing to arrive for the examination or failure to cancel your appointment to test without providing notice will forfeit your examination fee and you’ll have to register and pay again. 
• On Exam Day. Arrive at the testing center on your exam appointment date at least 30 minutes before the schedule. You must have your ATT and acceptable identification (driver’s license, passport, etc) that is valid, not expired, and contains your photo and signature.
• Processing Results. You will receive your official results from the board of nursing after six weeks.

Important list and resources you need to know if you’re taking the NCLEX: 

• 2023 NCLEX Candidate Bulletin. This resource is a comprehensive guide for the NCLEX, providing essential information and contact details for candidates. It covers registration procedures, test fees, scheduling , testing accommodations, exam rules, and what to bring to the test site. The guide also includes details on the check-in process, breaks, technical issues, and the testing environment. It explains the results reporting process and retake-policy and provides information on the content, development, and test plans of the NCLEX. Additionally, it discusses the passing standard, item formats, and decision rules for passing or failing the exam.
• Sample Questions and Exam Preview. Get a headstart on your exam preparation with these sample test packs by the NCSBN. 
• Candidate Tutorial. With the new item types, we highly recommend testing how the Next Generation NCLEX (NGN) works. This tutorial guides you on interacting with different question types in your NCLEX exam. It provides a representative sample of items you may encounter during the test, allowing you to practice their functionality.

Please visit our Nursing Test Bank page if you’re looking to answer more practice questions from different topics and different question formats.

Recommended books and resources for your NCLEX success:

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Saunders Comprehensive Review for the NCLEX-RN Saunders Comprehensive Review for the NCLEX-RN Examination is often referred to as the best nursing exam review book ever. More than 5,700 practice questions are available in the text. Detailed test-taking strategies are provided for each question, with hints for analyzing and uncovering the correct answer option.

Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items Next Generation NCLEX®-style practice questions of all types are illustrated through stand-alone case studies and unfolding case studies. NCSBN Clinical Judgment Measurement Model (NCJMM) is included throughout with case scenarios that integrate the six clinical judgment cognitive skills.

Saunders Q & A Review for the NCLEX-RN® Examination This edition contains over 6,000 practice questions with each question containing a test-taking strategy and justifications for correct and incorrect answers to enhance review. Questions are organized according to the most recent NCLEX-RN test blueprint Client Needs and Integrated Processes. Questions are written at higher cognitive levels (applying, analyzing, synthesizing, evaluating, and creating) than those on the test itself.

NCLEX-RN Prep Plus by Kaplan The NCLEX-RN Prep Plus from Kaplan employs expert critical thinking techniques and targeted sample questions. This edition identifies seven types of NGN questions and explains in detail how to approach and answer each type. In addition, it provides 10 critical thinking pathways for analyzing exam questions.

Illustrated Study Guide for the NCLEX-RN® Exam The 10th edition of the Illustrated Study Guide for the NCLEX-RN Exam, 10th Edition. This study guide gives you a robust, visual, less-intimidating way to remember key facts. 2,500 review questions are now included on the Evolve companion website. 25 additional illustrations and mnemonics make the book more appealing than ever.

NCLEX RN Examination Prep Flashcards (2023 Edition) NCLEX RN Exam Review FlashCards Study Guide with Practice Test Questions [Full-Color Cards] from Test Prep Books. These flashcards are ready for use, allowing you to begin studying immediately. Each flash card is color-coded for easy subject identification.

184 thoughts on “NCLEX Practice Questions Test Bank for Free”

How much are you charging for it?

Thanks for being generous

Thank you for your kindness & generosity. This is a big help for us, especially those with financial constraints.

How much for this

Thanks Matt Vera for your utmost effort in helping nurses to pass the exam

You’re most welcome! Good luck on your exams!

Hello Matt do you still have the Test Bank questions for 2021. If you do can I have them please and thank you.

Hi Winnie, Please visit our

Thanks heaps! Matt..

The site is very useful.

Thank you mam/sir

This is very helpful site. god bless🤗

Great website wish l knew about it before taking my nclex

Thank you so much for this free site. I found it just as helpful as Kaplan and Sanders which I paid for. I recommended this nurseslabs to some of my nurse friends preparing for the NCLEX. I used it to study and passed my NCLEX October 28. I will continue to use this as a reference. Once again Thank-You. A.Haynes RN

Hey Matt, I am impressed by your generosity. I couldn’t believe these were all free. In all fairness, there should be a tab for donations for the constant upkeep of the web. A very minimal way to show our gratitude.

Although I just started nursing school the i formation is mind blowing and very useful for me already. Thank you for your generosity. I will be using all the practice quizzes and test to prepare myself. Thank you again.

Thank you for this free nclex practice tests! May you have more blessings and success! I will take my exam next month.

Very informative and helpful

Thank you!You’re a big blessing to those who will take the exam.

I can’t thank you enough for this gift you have given us to use . God bless you.

Thank you so much Matt! This is helping me work toward my NCLEX with less pressure.

Thanks a lot can I get reading materials on PDF please

Thanks Matt Vera for ingenious effort.

You are heaven sent, Thank you Matt for helping us.

you guys all thank you so much for this massively hard work and huge success for all the nurses around the world .

Your efforts are immeasurable, you are not only helping nurses to pass their NCLEX exams but also increasing the number of qualified/competent nurses providing healthcare around the globe. We are grateful. I used this site to prepare for internal exams whilst I was in school and it really helped me. I’ll be writing NCLEX soon..

Planning to start this process, I think this will be so helpful to me. Thankyou very much

Thank you so much Nurse matt vera for this qbank,most beneficial, God bless you., if I may ask for some videos or pictures associated with the questions, will also help e.g lung sounds,abdominal sound etc thank you

I loved your blog and thanks for publishing this about NCLEX practice questions!! I am really happy to come across this exceptionally well written content. Thanks for sharing and look for more in future!! Keep doing this inspirational work and share with us.

My name is Daniel m Johnson from Tanzania I’m holding diploma in nursing and midwifery I’m looking for different nurse from different country so as we can share ideas and experience since I’m student I need to no much thing about nursing ….any one who is touched to please help me I wish to be came a good nurse and help different people from different society

What a wonderful thing to do for people! Thank you very much.

This very helpful to me, thank you.

You did a great job Matt…

This is so lovely

Very useful site. Thank you so much.

This is an amazing job Matt!! REALLY INCREDIBLE!!!

With all this I will certainly pass my NCLEX exams.

THANK YOU so so much Matt, this is great beyond measure.. I have been hook to this website. God will bless you and yours abundantly

You’re most welcome! :)

i just want to confirm for #39 it state pt need additional teaching so E should also be included to the answer cause it was contraindicated to MS right? . thank you :)

Yes, this has been corrected. Thank you! :)

Very informative and helpful. Thank you so much Sir/ madam

Thank you for providing regarding NCLEX preparation

Very informative. Thank you for update.

This is for sure the best nurse’s website ever. It really helped me a lot during my training.

Number 58 of NCLEX test 5 does not have the answers listed.

Hi Rebekah, this is now fixed. Thank you for letting us know!

This is very helpful

It’s very informative. Thanks

Thank you Matt Vera for providing information free of charge

Any advice of how well you can do on these question to build up your confidence?

Thanks a lot for great job. May the Lord Almighty shower His blessing upon you.

Thank you, this site is amazing. God bless you

Thanks alot.I,ve got a question What score ranges would be considered a Pass? I scored 69.33% overall. is that a Pass???

75% and above, from the analysis I got from a test after getting below 75

Thank you Nurse Matt. You deserve all the blessings! 🙏🏻😊

This is very helpful. Thank you Nurse Matt

Question 16 on practice test 9 asked about assessment during L sided CHF, yet the correct answer pertained to right sided HF. Just wanted to let you know…. Thanks for the practice questions! Appreciate all the work put into this.

Question 41 of NCLEX-RN Test 2 has two C choices. Thanks.

Hi, I like your questions, they’re very nice and challenging. Learning a lot from them.

I love this site.. Now all friends are learning serious from here

Thanks you guys are very generous

From Kenya, this site is so helpful,am learning a lot here.Thank you especially for the care plans.

Thank you so much

You Matt and your staff are such a blessing to us who will be taking the NCLEX RN exam. This site is very useful and helpful because it is very comprehensive and easy to understand. God bless and may tribe increase. Thank you so much

The site is very informative. I have learned a lot. Test questions are really amazing which I cannot find with other website. However, I got a low score, thus I need to further study especially on the areas wherein I got a below passing grade. I hope you will allow me. Thank you

thank you so much for creating this site for people like us. This excellent job. May God bless you in Jesus name —Amen

The Practice tests are awesome! The rationales are all well-explained which I love because it gives me more knowledge and insight. Thank you for creating this website free of charge.

Thank you so much. It was really helpful. I passed the exam. God bless real good.

Thank you Matt for the awesome and great website! its beyond compare. I want more practice test questions to hone my knowledge in Nursing practice, however, when I am trying to open one of the practice tests, I cant go through it. Could you please allow me? God bless

Thank you Matt for this practice test. Now I know my strength and weaknesses and will concentrate of the system that needs for further study. Can I practice more in practice test no 2? Please allow me to go trough with it. Kudos to you and your staff.

Hi this is what i got, im so nervous due to my nclex exam its gonna be this coming oct. Its doesnt say pass or not.

Your score 48% Categories Basic Care and Comfort 100% Health Promotion and Maintenance 53.85% Pharmacological and Parenteral Therapies 26.67% Physiological Adaptation 54.55% Psychosocial Integrity 100% Reduction of Risk Potential 36.36% Safety and Infection Control 100%

Thanks so much for this useful information. God bless you.

Thank you so much for all you do

The Practice tests are excellent. The rationales are all well-explained which I love because it gives me more knowledge and insight. Thank you for creating this website free of us. Remain blessed.

Like I am obsess with nurselab. A handy powerful tool, to keep you updated, thick and richly packed. You guys made reading so interesting and magnetic and very easy. Please do not stop. I recommend this to all nurses.

Love this. Thank you for sharing your generosity. I’ve been using this since I was still in college and I continue to use it until now.

Thank you so very much for this

I remain speechless but mostly grateful for your unconditional helpful assistance for this awesome richly throughout profound tool and opportunity given to me to increase my confidence, strengthen my knowledge, and be ready for my upcoming exam. Your questions and rationales are beyond my expectations. You are a God’ sent angel. Thank You. God Bless you. I will be forever grateful to you for making my dream come true! 🙌

This website can help me to review for NCLEX and it is for free! Thank you so much!

Amazing and really awesome job to you Matt and your entire team, may God replenish your source for giving us this for free. I have recommended to all my friends and family. Remain blessed and stay safe.

That’s very kind of you. Thank you so much! Bless you!

Your test questions have greatly helped me pass my NCLEX. I passed my NCLEX today and thank you to Nurseslabs. I came across this website by accident and I do not know how but it was divine intervention. I will definitely recommend Nurseslabs to my friends. The quality of the questions and rationales were very good and you would not think this is all for free the kind of work that came with it.

Kudos Nurseslabs and wishing all the future test takers all the best!

Wow Sam, congrats! What materials did you use other than nurseslabs? I’ve been answering nurseslabs also. My exam is on June. I hope I could also make it.

Thank you for this NCLEX sample test,as tool to determine areas i need to review/focus on for the proper exams.

This website can help me to review for NCLEX Thank you so much!

I just wanna ask why is that there are no more rationale posted after answering the question unlike before. Thanks by the way for the free and great Q & A bank. ❤

Sorry, we’re currently having some performance issues with that setup. Until we can resolve it, we have set each quiz to show results and rationales only after you have finished all the questions. Thank you for your understanding.

Hello, how do I get my score after taking the test to know if I am doing well or not

Hi, after you’re done answering all questions, the final item will direct you to the “Quiz Summary,” from there, click on the “Finish Quiz” button to get your final score.

Very great tool to study for the NCLEX. I passed my exam just by focusing on the questions and rationales provided here.

That’s great! Congratulations!

Thank you so much. It’s very helpful. God bless you…

Thank you for being generous. This is a big help.

I got 55/75.

Thank you so much for making this site.

Very helpful. Thank you and God bless…

Thank you so much, Nurse Matt for your generosity. Helping your fellow nurses and aspiring nurses to work abroad is such a selfless and noble act. God bless you and your team!

Thank you for your kind words, JB! Will pass on this message to the team. :) God bless!

The rationale after the question will really help us a lot specially when you are just using the question via online.

Hi Romel, we have temporarily changed this setting so that results and rationales will show only after you’ve finished the quiz. This is because we’re having some performance issues when using the previous setting. We’ll revert the changes once we’re sure the problem is resolved. Thanks for understanding!

I didn’t get my results after answering the 75 questions. Please why?

Hi Esther, did you click on the “Finish Quiz” button?

Thanks for all these questions where/how can i check my answers to these questions?

After answering the last item of the quiz, you’ll be redirected to the quiz summary. From there, click on the “Finish Quiz” button to view your score and results. You can also click on the “View Questions” button to review your answers and read the rationales.

Hi, thanks for providing so much useful information and all the test banks!

In RN practice Quiz 1:75 questions, for question 70, wonder if the correct phrase would be “would you NOT expect”?

Hi Cecilia, thanks for letting us know. We have corrected the question. Thank you! 🥰

Thank you for allowing me to practice the nurseslabs questions. The rationales are well explained. Thank you!

Thank you Ruth. Hope you’ve learned a lot from our practice questions. 🥰

God bless you

My name is Samuel. I just started with the RN practice questions. Thank you for the opportunity.

Hi, thank you so much for your generosity. Using this to prepare for my NCLEX and find it very informative. I will keep you posted on how it goes on the D-day

Frequently throughout the quiz, ARDS is given as “Adult Respiratory Distress Syndrome” instead of “Acute Respiratory Distress Syndrome”. This needs to be corrected.

Hi Bella, thanks for bringing this up.

Technically both terms are correct since “adult respiratory distress syndrome” is an earlier name referred to “acute respiratory distress syndrome” to differentiate it from respiratory distress syndrome in neonates and children. For the sake of uniformity, we have edited them to “acute respiratory distress syndrome”. You can read more about it here: https://doi.org/10.1164/ajrccm.149.3.7509706

This is so kind a gesture, remain blessed .The information is very understandable and helpful

I just wanted to thank you for taking the time to generate this website, this is really helpful and is free. God bless you

Thank you for your support and guide toward my nclex preparation.

Thanks for your generosity. I hope to pass my NCCLEX just on the first attempt Grateful for all your help

thanks for the help

Hi Sir, kindly explain why this question – The client with hyperemesis gravidarum is at risk for developing: Metabolic Acidosis is the answer. Thank you.

Quite familiar with the content. Thanks for this selfless initiative.

It has been a nice experience.

I love these practical questions. So helpful.

Thanks very much this is a good help for all students

Thank you for mett this free test which i have passed yesterday afternoon so ,it is greatest pleasure which will help me

Thank you so much for this great initiative.

Thanks for being kind God bless you

thank you for your help and kindness. It’s difficult to go back to school after 22 years of practice as a RN to take the test where you must cover a vast knowledge, which you do not use in everyday working (depends on the special field you are working. so I really appreciate your effort and dedication.

Matt Vera and all those helping us through this free medium, May God richly bless you abundantly. And may all your good desires come through

Hello Vera, I would start by thanking you for the great job you’ve done by helping us in our preparation for the exams. secondly would wish to know wther you have audio clips for lung, heart and abdominal sounds. thank you in advance and if any kindly let mh know pls.

What should we be scoring on these practice questions to let us know that we’re ready for the NCLEX

Do you have LPN test also?

Hi, please visit NCLEX-PN Practice Questions & Test Bank (200 Questions)

Thank you so much Nurse Matt you just don’t know how nurseslabs helped me in my nursing career and i even recommended nurseslabs to some of my friends. God bless you😊

Hi Matt, Thank you for this, indeed very helpful practice questions. Just a query though it says here to limit wrong answers to 15 or less? So is that the passing mark ? about 75-80%

Yes, that is correct. :)

Thank you so much for the practice questions. I learned a lot and it helped me to understand why I was getting my answers wrong. I used Kaplan and Saunders but it wasn’t helping me. I feel more confident than ever to retake my boards.

thank you…. wish this help a lot to my daughter to passed please pray for her God bless!!!

hi Matt, can l still use these question banks to study for the new NGN questions

Hi nurse Matt, May I gave all the questions please, need to prepare study for exam after been off school over 30 years, realize it for not giving up not try again, thank you 🙏

Thank you so much Nurselabs! I passed my NCLEX-RN exam using only your practice 75 question per day questions bank. I have a tight budget and not able to purchased online review and I just focused in answering your practice questions in just 2 weeks!!! Thank you for helping nurses! God Bless you more!

I want to practices questions

Hello Thanks so much for your good heart and good wish for us to practice and pass the NCLEX. Well appreciated. Please after your update I can’t get the answers and rationale to the 75 questions. This will help me to know my ability and where am lagging behind. Please how can this be rectified Thanks Hope

Hi Hope, did you finished all of the questions for the quiz? Your score together with the correct answers and rationale will only show after you’ve completed the whole quiz.

Hello Vera I finished all 75 questions submitted but no answer or rationale came up. I tried upto 3 times same. Even my friend I shared your content with complained of same thing, answers not coming. Please what can we do to access the answers and rationale Thanks Hope

What particular quiz?

Hello, great resource! I am a nurse that wants to help student nurses reach their full potential as nurses and pass the nclex. I would like to utilize your tests and quizzes to help my students learn to critically think through the questions and learn how to put their nursing knowledge to use. Would you allow me to utilize your questions in my content?

Thank you for the kind words! It’s awesome to hear that you’re dedicated to helping student nurses thrive. 🌟

Absolutely, you’re more than welcome to utilize our tests and quizzes for your students! We believe in collaborative efforts to strengthen the nursing community. Just ensure to give appropriate credit when using the content.

Out of curiosity, are there specific areas or topics you find students struggle with the most when preparing for the NCLEX? Maybe we can work together to create even more targeted resources!

Best of luck with your mission to guide the next generation of nurses!

Hi, I am studying for med surg 1 and med surg 2 upcoming exam. Need to pass both exams.

Sounds like you’ve got a busy study schedule ahead! MedSurg can be challenging, but with the right resources and dedication, you’ve got this. If you need specific materials, tips, or just a morale boost, don’t hesitate to reach out. Else, you can do practice all MedSurg exams on our Nursing Test Banks . Rooting for you to ace both exams! 💪

thank you so much… a big help

Hi Glacier and what a nice name!

You’re welcome! Really glad to hear the NCLEX practice questions were a big help. If you’ve got any other areas you’re prepping for or need more practice with, just let me know. Here to support your journey!

Thanks a lot @nurseslabs for this initiative I really believe by the time I sit my exam I will be a great nurse than ever before. I am learning a lot from the questions and explanation.

Hey Charles, You’re very welcome! I’m thrilled to hear that you’re finding our initiative helpful in your journey to becoming a great nurse. Remember, continuous learning is a key part of nursing practice, and it’s fantastic to see your dedication to it. If you ever come across any challenging topics or have questions about specific nursing concepts, please don’t hesitate to reach out. We’re here to support you every step of the way. Keep up the excellent work, and you’ll do great on your exam! 📖🏥🌟

Much help for beginners like us

Thank you so much Nurseslabs, I made it!!! Your practice exams, especially the rationales helped me a LOT…thank you!!!

Wow, that’s awesome news! 🌟 Huge congrats on making it through – your hard work and dedication really paid off. It’s super cool to hear how our practice exams and rationales played a part in getting you across the finish line.

Remember, this is just the beginning of an amazing journey in nursing. The field’s always changing and growing, and so will you. Keep that enthusiasm and curiosity going strong!

If you ever need a hand or just want to share your journey as you dive into your nursing career, give us a shout. We’re always here to cheer you on and lend support.

Big congrats again and best of luck out there!

Thanks for the information

thanks for the guide

Thank you for your kindness.

Thank you very much!

Thanks a lot for this whole range of knowledge; it’s now upon me to work extra hard to be a better nurse outside there or help other nurses be better at service delivery.

Hi Evans, You’re so welcome! I’m glad to hear that the range of knowledge from the NCLEX practice questions is empowering you to aim for excellence in nursing. Remember, every bit of effort counts towards becoming not just a better nurse but also a great mentor to others in the field. If you need more resources or advice along the way, I’m here to help. Keep up the fantastic work!

Please how can I practice questions please 🙏

In practice exam 5 question 22 asks about hyperemesis…. wouldn’t that cause alkalosis (rather than acidosis), since its acid from the stomach that is leaving the body?

Can I. Have free practice questions? NGN questions?

Thank you for the opportunity to know about all the information posted here. I strongly believe I will pass the NCLEX-RN exam at my first attempt through these useful resources available here. Thanks

Thanks a lot Nurselabs for the free test banks! It’s all what I focused to practice and read every rationale in each questions given. I just recently took my NCLEX-RN exam last week and i was able to make it. Your website is what i embraced and felt much comfortable and trusted what is in there. Thanks for helping lots of NURSES! Highly recommended!

Hello Brenda, Congratulations on passing your NCLEX-RN exam! 🎉 That’s a fantastic achievement, and I’m so thrilled to hear that our test banks and rationales were a valuable part of your preparation. Thank you for trusting Nurseslabs and for your kind words—it means a lot to us.

If you have any tips for future test-takers or any other resources you found particularly helpful, we’d love to hear about them. Your feedback not only celebrates your success but also helps us continue to improve and assist other nursing students.

Thanks again for recommending us, and best of luck in your exciting nursing career!

THIS IS GREAT. THANK YOU FOR SHARING.

Hello, Thank you for your good work. Are you uploading new practice tests or comprehensive tests for nclex rn or nclex pn soon? It has been a while.

Hi Monica, Thank you for your kind words! We appreciate your support. Yes, we are planning to upload new practice tests and comprehensive tests for both NCLEX RN and NCLEX PN very soon. Stay tuned for updates!

thanks for update ..be blessed

You’re doing great!!!! Thanks

Good day sir, please am Thomas from ghana and I want an assistance to enable me pass NCLEX test.

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Health Psychology: Theory, Research and Practice

Student resources, multiple choice questions.

1. Pain has been described as ‘an aversive, personal, ______ experience, influenced by cultural learning, the meaning of the situation, attention and other psychological variables, which disrupts ongoing behaviour and motivates the individual to attempt to stop the pain’ (Melzack and Wall, 1988).

• nerve-shattering

2. Pain has also been described as ‘whatever the person experiencing it says it is, ______ whenever the experiencing person says it does’ (McCaffery and Thorpe, 1988).

3. The specificity view of pain was described by ______ in 1664.

4. A pain persisting for three months or more that tends not to respond to pharmacological treatment is called ______.

5. The best known and most frequently used pain questionnaire is the ______.

• Sickness Impact Profile
• Bio-behavioural Pain Profile
• Pain Information and Beliefs Questionnaire
• McGill Pain Questionnaire

Read the passage and fill in the missing words using the options that follow.

Herr, Bjoro and Decker (2006) found that there is no (6) ______ tool based on (7) ______ pain indicators in English that can be recommended for clinical practice. It is therefore necessary to rely on the reports of (8) ______ others (e.g. carer, interpreter), which has additional challenges of (9) ______, interpretation, and motivation.

6. Which is the best option?

• nonverbal/behavioural
• standardized
• significant

7. Which is the best option?

8. Which is the best option?

9. Which is the best option?

Read this passage and fill in the missing words using the options that follow.

The (10) ______  receives inputs from nociceptors that it projects to the brain via a (11) ______. The (10) ______ also receives information from the brain about the psychological and emotional state of the individual. This information can act as an (12) ______ that closes the (11) ______ preventing the transmission of the nociceptive impulses and thus modifying the perception of pain. The (13) ______ operates based on the relative activity of the peripheral nociceptor fibres and the descending cortical fibres. Pain impulses must reach conscious awareness before pain is experienced. If awareness can be prevented, the experience of pain is decreased, eliminated or deferred.

10. Which is the best option?

• neural gate
• inhibitory control
• dorsal horn

11. Which is the best option?

12. Which is the best option?

13. Which is the best option?