Nursing continuing professional development (CPD, previously known as nursing continuing education or CNE) articles provide authors with an avenue for a deeper dive into topics. Although these articles can prove challenging for newer writers, don’t be daunted. Whether it’s a complex clinical (such as pharmacokinetics) or professional (such as the ethics of organ donation) topic, CPD articles provide the perfect venue for delivering information you want to share.
These articles require readers to provide evidence of learning before they can receive credit. Different options exist, but the most common is a post-test consisting of multiple-choice questions. This structured format facilitates easy scoring and the ability to compare learners. The comparison can alert authors to areas of unclear information or poorly written questions.
Frequently, journal staff write the post-test, but in other cases that task falls to the author. Like the CPD article, writing multiple-choice test questions can prove intimidating, but as with any other skill, understanding basic principles and practicing will enhance your confidence.
Nuts and bolts
A multiple-choice question consists of three parts:
- the stem (question)
- the correct answer
- the distractors (incorrect answers).
Your questions should reflect the objectives and learning outcomes for the article. Objectives are typically based on Bloom’s Taxonomy of Learning, which divides learning into six levels of increasing complexity: knowledge, comprehension, application, analysis, synthesis, and evaluation. For example, let’s say one of your objectives is that the learner will be able to interpret arterial blood gas results for patients with acute respiratory distress syndrome (application level). One of your questions might be to provide a set of results, then offer possible answers that require the learner to interpret those results, thus applying what they’ve learned. (Another excellent resource for writing objectives is the work by Robert Mager. This short article provides an overview of his work.)
Tips for writing the stem include:
- Be clear and succinct. You don’t want the learner to have to read the question multiple times to understand it.
- Focus on a single idea or concept.
- Phrase the stem as a question or ask the learner to complete a sentence.
- Avoid negative words such as “not” or “except,” which can be easily misread by the learner. If you must use them, bold or capitalize them.
- Avoid absolutes such as “always,” “never,” “all,” and “none.”
- Avoid vague terms such as “may,” “could,” “often,” and “usually.”
- Be sure the question you write doesn’t provide an answer to a subsequent question.
Tips for writing the answers include:
- Write the correct answer before writing the distractors.
- Keep the distractors plausible. When writing them, consider mistakes clinicians might make in practice.
- Make all the possible responses similar in length and grammatical structure.
- Check for subject-verb agreement with the stem. For example, you don’t want the subject in the stem to be plural and one of the answers to be singular.
- Avoid absolutes such as “always,” “never,” “all,” “none,” “all of the above,” and “none of the above.”
- Don’t try to trick the learner. The goal is to fairly assess what they’ve learned.
You’ll also usually need to include a rationale for the correct answer.
Here’s an example of a well-written multiple-choice question.
Which of the following is a common symptom of hypercalcemia?
- Bone pain
- Shortness of breath
- Excessive sweating
- Increased appetite
Correct answer: A. A symptom of hypercalcemia is bone pain. Other signs and symptoms include changes in mental status, poor appetite, thirst, constipation, nausea and vomiting, low urine output, and coma.
Note that this question has four possible answers, the most common number. You’ll want to have the same number of options for each question in the test.
After you’ve written all the questions, tally the number of times each letter appears as the correct answer to be sure you haven’t favored one letter over another. For example, in a 12-question test, you wouldn’t want 6 “b” correct answers. Also avoid having several answers in a row with the same correct letter. Mix up the order of correct answers.
Case scenario combination
To encourage critical thinking, consider combining a case scenario or vignette with multiple choice questions. For example, you might present the case of a patient with a subarachnoid hemorrhage. The scenario would begin with relevant patient information, such as signs and symptoms and history. The questions, often framed as decisions a clinician would need to make, would ask learners about the patient’s diagnosis, treatment, and nursing care.
You can create a case scenario based on your clinical experiences. Be sure to note that the “case” is not a real patient. If you use an actual patient, change all identifying information and note that you have done so. It’s usually better to create a hypothetical patient because you can fit the circumstances to meet your need to assess the objectives. One final piece of advice: Don’t make the scenarios too long.
A word about AI
Some writers have turned to artificial intelligence (AI) for help in crafting multiple choice questions. Research as to the accuracy and effectiveness of AI in this area is limited. One interesting (2025) study by Law and colleagues compared questions developed by ChatGPT-40 with those generated by humans. The AI-generated questions tended to be easier and tested lower-level cognitive skills compared to human-generated questions. In addition, the AI-generated questions were more likely to have factual errors. However, using AI to generate questions saved time. The researchers concluded that a combination of AI and humans is needed, with AI creating the questions, and humans reviewing, refining, and validating them.
The article “22 top AI quiz and exam generators to test your students’ knowledge with ease” discusses the use of AI quiz generators and reviews 10 free ones. However, it’s important to remember that these haven’t been researched to determine their effectiveness. If you choose to use AI to assist you in developing questions, review (particularly checking for accuracy) and revise as needed. You’ll also need to disclose the AI use when you submit the article. Unless you’re generating a large volume of multiple-choice questions, my advice at this stage is to write them yourself, while watching for future developments in this area.
An art and a science
Like nursing, writing multiple test questions is an art and a science. The best practices I’ve outlined here form the science part. The art comes in creating effective case scenarios and writing plausible distractors. By applying art and science, you can ensure your questions fairly measure whether the reader has met the article’s objectives.
Hi, I’m Cynthia Saver, MS, RN, owner of CLS Development, which provides writing and editing services, and editor of Anatomy of Writing for Publication for Nurses, 4th ed. I’m also past editorial director for American Nurse Journal.
I’ve been a full-time professional nurse writer and editor for many years, and that doesn’t count the writing I did as I fulfilled my nursing roles in clinical, research, education, and management. My passion is helping nurses share their expertise through the written word, including, but not limited to, publication. Writing can be scary and intimidating. I hope to make it less so and to help you develop your writing skills the same way you’ve developed your nursing skills.
Whether you’re considering your first or your 50th publication, want to contribute to your organization’s newsletter, or crave to be a better communicator online and in print, I hope you’ll find what I write helpful. The nurse publishing colleagues I’ve learned from over the years (many of whom are contributors to my book) may not be listed by name, but I’m grateful for their willingness to share. In that spirit, I’m looking forward to sharing with you! If you have feedback, feel free to email me at csaver57@gmail.com.
Reference
Law AKK, So J, Lui CT, et al. AI versus human-generated multiple-choice questions for medical education: A cohort study in a high-stakes environment. BMC Med Edu. 2025;25(1):208. doi:10.1186/s12909-025-06796-6
Salmon N. Writing a continuing professional development activity. In: Saver C. Anatomy of Writing for Publication for Nurses. 5th ed. Indianapolis, IN: Sigma Theta Tau International; 2024; 267-82.
Veillette H. Advance your writing skills: Craft effective multiple-choice questions for continuing education activities. AMWA. 2024;39(3). doi:10.55752/amwa.2024.376
