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The BEST Way to Deal With One of Test-Takers’ WORST Problems: Qualifiers

Identifying Qualifiers and Eliminating Distractors

When I wrote about the mistakes people make on exam items, I mentioned qualifiers. These are words that alter a statement’s meaning. In a multiple-choice exam, qualifiers in the question (what test-makers call the “stem”) can make the difference between choosing the correct answer or an incorrect distractor.

animated brain activityIn this post, drawing on and expanding the work of Cornell professor Walter Pauk, I will identify and describe several families of qualifiers:

  • Presence–is, is not
  • Quantity, extent–great, much, little, no, most or least
  • Quantities–all, most, some, none (no), only
  • Quality–good, bad, best, worst
  • Comparisons–more, equal, less
  • Frequency–always, usually, sometimes, never,  seldom, rarely

Pauk does not mention “first” but I find this qualifier often appears in exam items for healthcare professionals.  It’s often a “most” question in disguise, as in, “most important.”

Here are my top tips for coping with qualifiers in the stem:

Identify the key word. “Which of these actions…”, or “which of these reflexes…” or “which of these medications…” and so forth. This helps you to stay focused on what you’re looking for.

In most cases, assume that all the options listed are possible, desirable, doable, and logical.

Then, look at them in the light of which option would be the answer based on the qualifier.

Think about the task you are being asked to do.

Unlike questions that require recall of knowledge, questions that contain a qualifier almost always test your ability to apply knowledge.

Treat each option as a true/false when dealing with presence/absence items.

These are the only ones for which the qualifier does not imply that all are possible (for example, “Which of these is NOT…”) To deal with these questions, find the three options that are true statements; the answer that is false is the correct option. Fortunately, the IBLCE exam no longer asks many “not” questions.

For quantity/extent items, assume that all options are possible.

Questions that have a qualifier of “most” are almost always testing your ability to prioritize, such as in “Which of the following (actions, symptoms, observations, etc.) would be MOST important…” To deal with this, try asking yourself which option would provide the most benefit, or which one would avoid the biggest consequence.
Conversely, questions that have a qualifier of “least” imply that all are possible and even likely. Here, you are being tested on your ability to identify the one thing that is of little or no importance to the case’s clinical management. To deal with this type of question, ask yourself: If I could do only three of these actions, which one would I eliminate?

Quality items are similar to a “most” question, so assume that all options are possible—perhaps even good! You may be faced with something like: “Which of these actions would BEST resolve…?” This question tests your ability to analyze and choose the best from among good options. To deal with this, think about which action, in these circumstances, offers the best chances for achieving the desired outcome.

Remember that sequence questions tend to test your ability to prioritize.

However, in some cases, it tests your ability to know the sequence of steps in a procedure. Here’s an example: “When assembling a (whatever), which would you do FIRST?”

Recognize comparison questions.

I doubt you’ll see this, because these qualifiers lend themselves to questions that test the examinee’s ability to recall rather than apply information. However, these qualifiers could be used to test your recognition of how age/development affects issues. “In comparison to a term infant, a preterm infant’s risk for jaundice is…” and the answer would be more.

A frequency qualifier such as “usually” tests your ability to recognize a condition’s distinguishing feature, but gives the test writer “wiggle room.”

These questions are often disguised as “most” questions: “An infant with this condition is MOST likely to experience…” Humans aren’t machines, and hence something that occurs often or even most of the time doesn’t always happen. I don’t think there is any special strategy here. Don’t make these harder than they are.

Re-read, and make sure that you have a rationale for picking the option you picked. If you don’t have a rationale, maybe you didn’t pick the right answer.


On a scale of 1 to 10, how prepared do you feel to deal with qualifiers on the IBLCE exam?

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