Stem and lead-in (multiple choice questions)

A.Prof Frank Gaillard et al.

The stem and lead-in are the first parts of multiple choice questions and are sometimes rolled into one short sentence or phrase. 

These have a dual purpose: 

  1. provide context for the question and provide any relevant information
  2. instruct the examinee exactly what needs to be done to answer the question correctly
  • A 45-year-old man complains of back pain and haematuria. [stem]
  • What is the most likely cause? [lead-in]
  • What is the most common cause of haematuria? [combined stem and lead-in] 
  • clear: the stem should be clearly written, and unambiguous; do not try and trick the examinee
  • short: try and keep the stem as short as possible without, however, diminishing comprehension (e.g. avoid acronyms)
  • avoid negatives
    • in most instances, stems should be worded to achieve a positive/true answer, as this reinforces knowledge. 
      • positive: "In what demographic is MS most common?" 
      • negative: "In what demographic is MS least common?"
    • sometimes the learning goal is a negative answer and if this is the case the negative term should be ALL CAPS and emboldened (e.g. "Which of the following is FALSE?") to avoid misreading
    • read more about negative questions
  • avoid double negatives: double negatives are never needed and should be avoided
  • use the present tense
    • generally, the stem should be in the present tense  (e.g. "A 50-year-old male presents with abdominal pain and a CT scan is performed")

When writing the stem, try to stick to a natural order that places content in an order that has maximal readability and limits confusion:

  1. age/sex
  2. relevant history
  3. presenting signs and symptoms
  4. what was done
  5. lead in question

The lead-in follows the stem and is used to instruct the examinee as to exactly what is required to answer the question correctly. It can either be in the form of a question or a phrase needing completion. 

  • question-type lead-in
    • "What is the most likely diagnosis?"
    • "Which of the following is FALSE?"
  • completion-type lead in
    • "The third branch from the arch of the aorta is..."
    • "All of the following are reasonable diagnoses EXCEPT..."

It is essential that for the completion type lead-in, that the alternatives (see below) are phrased in such a way that they grammatically finish the lead-in appropriately – in other words, you should be able to read the lead-in followed by each alternative, and it should make sense. 

Both the stem and lead-in should have normal sentence capitalisation and punctuation. There are a few special notes specific to multiple choice questions:

  • question-type lead-ins should finish with a question mark ( ? ) 
    • e.g. "What is the most likely diagnosis?"
  • completion-type lead-ins should finish with an ellipsis ( ... )
    • e.g. "The most common cause of a headache is... "
  • if the lead-in is asking to pick the single wrong answer (negative question) the negative word should in be in ALL CAPS and emboldened, to make it harder to misread
    • e.g. "Which of the following is FALSE?"
Help and Style Guide
Share article

Article information

rID: 50229
Tag: help
Synonyms or Alternate Spellings:

Support Radiopaedia and see fewer ads

Updating… Please wait.

Alert accept

Error Unable to process the form. Check for errors and try again.

Alert accept Thank you for updating your details.