ExamEval
Item Writing Flaws
None of The Above

Why "None of the Above" Should Not Be Used in Multiple-Choice Questions

By Sean P. Kane, PharmD, BCPS

Published June 25, 2025

"None of the Above" Encourages Overthinking

"None of the above" is a common answer choice in multiple-choice exams, but its use is often more harmful than helpful. While it may seem to add rigor or challenge, in reality it can undermine the validity of an assessment and penalize thoughtful students. Instead of testing true knowledge, it can shift the focus to technicalities and ambiguity.

The core problem with "none of the above" is that it becomes problematic when the answer choices are not absolutely false. Test-takers commonly overthink and find fault or an edge-case scenario in which each answer choice is false, leading them to incorrectly select "none of the above" on a technicality and not due to a knowledge deficit.

Consider the following example:

Headache Treatment

Which of the following over-the-counter treatments is most appropriate for temporary relief of mild, occasional headache?

A. Acetaminophen 4000 mg PO QID

B. Aspirin 81 mg PO daily

C. Naproxen sodium 220 mg PO BID ✓

D. None of the above

The intent of this question is for a student to demonstrate knowledge of the correct drug and dose for self-care of headache. The problem with this question is that a student is likely to find fault with the correct choice (answer C) and select "none of the above" instead. A student might argue answer C is incorrect based on the patient age (naproxen is not indicated in children less than 12 years old and the question does not specify age), dose (naproxen OTC labeling allows for dosing of 220 mg Q8-12hr, not just BID), or drug selection (naproxen would be avoided in certain patients, such as those with heart failure or uncontrolled hypertension).

Critical Issue

"None of the above" can introduce construct-irrelevant variance by encouraging students to focus on minor technicalities or exceptions rather than the core concept being assessed. This can lead to knowledgeable students being penalized for overthinking, while less knowledgeable students may guess correctly.

"None of the Above" Prevents Answer Choice Ranking

The optimal multiple-choice format requires students to rank or order the answer choices from least to most appropriate, selecting the single best answer based on the scenario. When "none of the above" is used, it fundamentally changes the question into a true/false format. In that situation, test-takers need to decide if any of the listed options are absolutely correct or not, rather than evaluating and ranking them. This approach is less preferred, as it reduces the cognitive complexity and discriminative power of the question.

Replace "None of the Above" with a Specific Action

The best way to address this item writing flaw is to replace "none of the above" with a specific, negative option of what should not be done. Examples could include:

No drug therapy is indicated at this time
No laboratory monitoring is needed at this time
No imaging is indicated at this time
No antibiotics are needed for this diagnosis
No referral to a specialist is required at this stage

By adjusting the answer choice to be more specific, students can now rank answer options and are less likely to pick an incorrect answer choice due to overanalyzing edge cases in which all answer choices are incorrect.

Example of None of the Above in Health Sciences Education

Flawed Question

A 68-year-old woman is undergoing bone mineral density evaluation as part of routine screening for osteoporosis. Her T-score is -2.7, and her 10-year FRAX probability of major osteoporotic fracture is 24%. Which of the following is the most appropriate treatment at this time?

A. Alendronate 70 mg PO once weekly ✓

B. Raloxifene 60 mg PO once daily

C. Romosozumab 210 mg subcutaneous injection once monthly

D. None of the above

Although the correct answer is choice A, a student who overthinks the question may incorrectly select choice D (none of the above) due to nuances such as contraindications, patient preference, rare clinical scenarios, or subtle differences in doses or bisphosphonate choice (e.g., daily vs. weekly alendronate dosing, IV vs. PO bisphosphonates, alternative oral bisphosphonates, etc.). Selection of "none of the above" does not specifically indicate whether the student would recommend an alternative drug therapy option or that there is no need to initiate a drug at this time.

Corrected Question

A. Alendronate 70 mg PO once weekly ✓

B. Raloxifene 60 mg PO once daily

C. Romosozumab 210 mg subcutaneous injection once monthly

D. No drug therapy is indicated at this time

The corrected question replaces "None of the above" with a more specific negative option. This approach allows students to rank the answer choices and select the best initial therapy (or no therapy), rather than overanalyzing edge cases where each drug therapy option might not be appropriate and incorrectly defaulting to "none of the above".

Ambiguous answer choices like "none of the above" can quietly undermine the validity of high-stakes assessments, leading to unreliable results and missed opportunities for meaningful learning improvement. Left unchecked, these flaws can penalize careful students and obscure true competency. ExamEval, an AI-powered exam analysis platform for health professions educators, solves this problem by automatically detecting item-writing flaws, increasing assessment reliability, and supporting improved student learning outcomes with expert-level precision.

References