Patient Focus

Question 1

1. Mavis has recently been widowed and has a history of mild dementia.
   She was admitted several weeks ago with pneumonia, which
   has gradually resolved. She worked hard with the physiotherapy team
   and has returned to her functional baseline level of activity. Despite this,
   her family highlights several concerns which the nurses are keen for you
   to address before Mavis is discharged.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Assist Mavis’s daughter-in-law, who feels that Mavis requires a lot of
   help with looking after her bungalow.
   B Address her son’s concerns about possible fi nancial exploitation by a
   neighbour, using the appropriate assessment tools.
   C Address her brother’s concerns that her memory loss is becoming
   much worse and she needs further medical treatment.
   D Discuss the family’s concerns with Mavis, and obtain her perspective
   fi rst.
   E Assist the nephew who has asked you to arrange a nursing home for
   Mavis, where she can be supervised, in case she falls.

Answer 1

1. D, C, A, B, E
   Doctors must work in their patients’ interests, while respectfully considering
   the valuable input of family and friends. The best answer is
   (D) because it is essential to gain the patient’s perspective on each concern
   in order to address the need for intervention. (C) has the possibility
   of resolving all of the family’s concerns if the patient’s cognitive decline
   is remediable, although it obviously neglects involving the patient in your
   eff orts. You can consider arranging the remaining options in terms of
   their order of severity and the likelihood of you being able to help. An
   assessment by the occupational therapist usually identifi es and addresses
   any potential problems with ability to function at home (A). Financial
   exploitation lies outside the immediate remit of the clinical team; however,
   it would be inappropriate for you to ignore any legitimate concerns
   (B). A local vulnerable adults’ nurse or social worker is most qualifi ed
   to make the appropriate assessments, not a foundation doctor. (E) is a
   wrong answer as there is no objective evidence of falls in the question,
   and, in any event, a nursing home would not be the fi rst step to avoiding
   these in future.

Question 2

2. You have arranged some bedside teaching for a group of six
   medical students with a patient on your ward who is suff ering from
   multiple sclerosis. On arrival you fi nd her to be in emotional distress
   due to worsening of symptoms and a recent fi nancial dispute with her
   family. You had previously agreed to spend 45 minutes with the patient
   and students, and do not have any other patient with whom you could
   teach the students.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Teach the students clinical theory in a classroom instead.
   B Explain that emotional turbulence is a normal part of chronic disease,
   and continue with the bedside teaching as planned.
   C Attempt teaching, but agree that if she continues to be upset you are
   happy to discontinue.
   D Teach the students a lesson in communication skills by exploring her
   family issues.
   E Ignore the issue altogether and restrict your teaching to brief examination
   of the patient’s neurological system.

Answer 2

2. A, C, E, B, D
   While it is unfortunate to compromise your teaching commitments,
   hospitals exist for patient well-being fi rst and foremost. There are other
   ways in which the teaching time can be eff ectively utilized and therefore
   (A) would be the most preferable. A willingness to discontinue is less
   ideal (C), but better than the remaining options as it acknowledges the
   patient’s vulnerability. (E) makes no attempt to even acknowledge the
   patient’s distress and is therefore worse, but has the benefi t of being
   brief and focused on examination which will not necessarily antagonize
   the patient. In contrast, (B) is an incorrect response; the patient’s distress
   is trivialized into a generic statement about chronic disease, and
   teaching continues completely unaltered, prolonging the distress for the
   patient. (D) represents the worst response, as it is likely to worsen the
   situation by exploring personal family problems in an inappropriate setting
   with an audience of six medical students.

Question 3

3. You are a foundation doctor working in a GP surgery and have
   spent the morning assessing an infant with possible meningitis,
   admitting a young man with suicidal ideation, and breaking the news of a
   pancreatic malignancy to a previously healthy 55-year-old. Prior to your
   lunchtime home visits, a 60-year-old man visits your practice for the
   fourth time in two months with generalized worsening ‘aches’, despite
   normal examination, investigations, and maximal medical therapy. Your
   ten-minute consultation fails to assuage him.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Explain that you must see other patients with serious life-threatening
   conditions, and you do not have the time he requires.
   B Ask whether he would be interested in the services of complementary
   health providers.
   C Refer the patient to a rheumatologist.
   D Spend ten minutes focusing on the patient’s psychological and social
   well-being.
   E Off er the patient the advice of another doctor at the practice.

Answer 3

3. D, C, B, E, A
   In any frequently attending patient, it is important to address their background
   and beliefs to identify any underlying concerns that might be
   bringing them back. (D) is therefore the best answer, as although the
   appointment is likely to overrun, it is sometimes necessary to off er additional
   time, and you may be able to deal with this otherwise complex
   problem. It is obviously better that you are able to resolve the patient’s
   problems yourself, but if this is not possible, seeking the input of aspecialist colleague might be sensible in case you and your colleagues
   have missed something (C). A trial of non-traditional therapy (B) implies
   that you have exhausted all appropriate medical therapy (provided of
   course the diagnosis is correct), and would be a correct option once
   you had fully explored the patient’s psychosocial well-being or sought
   specialist advice as above. A fourth colleague at the practice is unlikely
   to be able to add anything further to the patient’s current management
   and represents a misuse of the practice’s resources (E). You should treat
   each patient independently of other cases; your previous clinical encounters
   during the day are irrelevant to the care you should provide to this
   patient. Hence informing your patient about more ‘serious’ cases would
   obviously be the least appropriate option (A).

Question 4

4. A patient appears to be worried during your surgical ward round,
   and the consultant suggests the need to ‘get to the bottom of these
   worries before we explore the diff erent treatment options’. You consider
   how you might go about doing this.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Allow the patient to express their concerns when they choose and
   without directly asking.
   B Ask the nurse looking after the patient today to explore any concerns.
   C Ask the healthcare assistant (HCA) looking after the patient today to
   explore any concerns.
   D Speak to the family to identify any concerns that the patient may have.
   E Set aside 20 minutes to speak with the patient to establish any underlying
   concerns.

Answer 4

4. E, D, A, B, C
   It is your responsibility to work in partnership with your patients and
   establish and maintain eff ective relationships with them. (E) is an arbitrary
   time to spend with the patient, but it does what is necessary to
   address your consultant’s request. (D) is less direct, although a collateral
   history from the family may shed some light on the patient’s concerns.
   (A) does not really address the problem as no questions are asked and
   is therefore the least eff ective ‘correct’ answer. (B) and (C) are incorrect
   and represent inappropriate delegations which are unlikely to lead
   to the desired outcome, with a nurse (B) being only slightly preferable
   to an HCA (C).

Question 5

5. One of your patients appears to be very depressed, which she
   believes to have been precipitated by a recent bereavement. You
   realize that her loss parallels one of your own experiences and wonder
   how this might be used to develop rapport with your patient.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Describe your own loss and subsequent feelings in detail.
   B Explain how you can empathize with her because of your own
   similar loss.
   C Acknowledge her understandable sadness from experiencing a
   personal loss.
   D Change the subject, as dwelling on it may make her more upset.
   E Encourage her to discuss her feelings with a friend, family member, or
   religious leader.

Answer 5

5. C, E, B, D, A
   In caring for any patient, you should show compassion and develop rapport
   whilst maintaining an adequate professional distance. This balance
   is best made by (C). Nothing in the question invites the response in (E),
   but it might be helpful to share her personal feelings with someone close
   whom she trusts. (B) is generally wrong, as it involves disclosing some
   personal information about yourself, but it may not always be wrong
   and it could have a positive eff ect in some patients. (D) is worse as it
   is dismissive and misses an opportunity to explore an important issue.
   The worst answer is (A), as it is very unprofessional, irrelevant, and may
   disrupt the relationship with your patient.

Question 6

6. You are working as an FY1 doctor on the gastroenterology
   ward. Maureen has early dementia and declines further treatment,
   despite the medical team’s recommendations and her daughter’s
   insistence. Her daughter explains about a previous protracted debate
   between other doctors and her mother, which led to Maureen eventually
   being ‘overruled’, and asks you to avoid a similar delay and initiate
   treatment straight away.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Assess Maureen’s capacity for refusing this treatment.
   B Read through the notes and establish whether Maureen lacks capacity.
   C Ask the daughter to help in your assessment of Maureen’s capacity.
   D Just get on and treat Maureen irrespective of her wishes.
   E Avoid the decision and seek the input of a superior.

Answer 6

6. A, E, B, C, D
   The patient’s wishes must always be followed, even when contrary to
   their perceived best interests, provided that the patient has capacity
   to make their own decisions. No diagnosis (e.g. dementia) precludes a
   patient having capacity, which must be assessed in each case in a time- and
   decision-specifi c manner. Therefore (A) is the only correct answer. (E) is
   unnecessary but it is not incorrect or dangerous. (B) implies an incorrect
   defi nition of capacity, although the medical notes may be able to shed
   some light onto the patient’s previous state, e.g. prior loss of capacity,
   known dementia, Abbreviated Mental Test Scores on admission, and istherefore not completely useless. (C) places an unfair burden on the
   daughter and is inappropriate and incorrect, and it is unhelpful to involve
   a family member in this way. However, (D) is the worst answer as it
   completely ignores the patient’s autonomy, and is possibly illegal.

Question 7

7. You are seeing Derek, a 45-year-old man. He specifi cally mentions
   to you his relative who has recently been diagnosed with cancer.
   This news has concerned him, and Derek is worried about his own risk
   of developing cancer. Having done some reading on the internet, he is
   requesting a full-body CT scan.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Explain the dangers of X-radiation and the associated increased risk
   of cancer.
   B Explain that his absolute risk of developing cancer is low.
   C Take a history and examination.
   D Off er a full-body CT scan.
   E Prescribe anxiolytics.

Answer 7

7. C, B, A, E, D
   This question requires you to address patient concerns while also providing
   reassurance when appropriate. Derek has not off ered a suitable
   indication for a CT scan, but the correct response is to conduct a full
   assessment, as other decisions can’t be made without this (C). While the
   patient’s risk of developing cancer may be low, you are given no information
   to be certain of this; it is quite possible the patient may have a cancer
   syndrome that predisposes him, which makes (B) a less appropriate
   response. (A) is a fair thing to explain but does not address the patient’s
   anxieties. (E) is obviously incorrect without further clinical information,
   and not very much better than ordering an inappropriate scan (D).

Question 8

8. You are reviewing a man who is troubled about his weight. Despite
   having tried various dieting and exercise plans, he is now requesting
   medication for weight loss. His body mass index (BMI) is currently 35,
   and under local policy guidelines he has not yet reached the BMI required
   to commence this treatment.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Write him a prescription, as he has exhausted alternative options.
   B Explain the high cost of this medication, and encourage him to seek it
   from wholesale online distributors instead.
   C Write to the Clinical Commissioning Group (CCG) asking permission
   to prescribe the medication.
   D Inform the patient that he is not of a high enough weight to benefi t
   suffi ciently from the medication.
   E Refer the patient to another doctor in the practice.

Answer 8

8. D, A, E, C, B
   GMC guidance states that drugs should be prescribed to meet the needs
   of patients and not simply because a patient demands them. (D) represents
   the honest answer and follows evidence-based/locally agreed
   guidelines. (A) is an alternative approach and your prerogative, although
   you would need to have good reasons for doing something diff erent to
   the consensus of your colleagues. (E) is likely to be unhelpful, as it simply
   defers the decision-making to a colleague, although it is not incorrect.
   (C) might be necessary if you wanted funding for a drug, but it is not
   necessary to prescribe it. (B) is the only explicitly wrong answer, as it
   may be unsafe for the patient to purchase medication from an unlicensed
   supplier.

Question 9

9. You are asked by one of the nursing staff to see Heather, a patient
   who is refusing elective coronary angiography following a non-ST
   elevation myocardial infarction.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Establish her concerns.
   B Take the patient to see a coronary angiography being performed.
   C Discuss her decision with family members if Heather agrees.
   D Explore alternative treatment options, their risks and benefi ts.
   E Explain the benefi ts of the procedure and insist that she must have it done.

Answer 9

9. A, D, C, E, B
   It is necessary to foster a professional relationship with every patient by
   establishing rapport and understanding their concerns, and this may lead
   to identifying why the patient is refusing the procedure, and possibly how
   to overcome this (A). (D) is not incorrect and might allow the patient’s
   concerns about the procedure to be answered, albeit indirectly, but is
   less eff ective than (A). (C) is also not incorrect but is unlikely to achieve
   a resolution, and is less appropriate than exploring the patient’s concerns
   directly with the patient. (B) and (E) are clearly incorrect answers and it
   is diffi cult to decide which is worst. It is never appropriate to insist on a
   patient having a treatment unless they do not have capacity and a ‘best
   interests’ decision has been made (E); instead the pros and cons of each
   option should be discussed with the patient. This option is probably not
   the very worst action, as it stops short of actually going ahead with the
   procedure without the patient’s consent (i.e. battery). (B) is probably
   marginally worse than (E), as it is completely inappropriate for the patient
   and breaches the confi dentiality of another patient at the same time.

Question 10

10. You are about to share a list of ward jobs after the consultant
    ward round with your SHO on the oncology ward. You both have
    plenty of tasks to keep you busy until the end of your shift. The SHO tells
    you to delay referring Mrs Wilson to the palliative care team until tomorrow,
    as she is likely to need infusion pumps and will create other tasks which
    will take too long. You are concerned as she seems to be in pain.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Complete the list of jobs that your SHO has assigned to you before
    referring the patient to the palliative team at the end of the day.
    B Delegate the task of referring the patient to a nurse although you
    know that ‘doctor to doctor’ referrals are expected.
    C Complain to your consultant that the SHO is neglecting Mrs Wilson.
    D Explain the importance of adequate analgesia in terminal patients to
    your SHO and suggest that the jobs be reprioritized.
    E Follow your colleague’s instructions and make the referral to the palliative
    care team tomorrow.

Answer 10

10. D, C, B, A, E
    Your fi rst duty should be towards your patient; Good Medical Practice also
    reminds us to work with colleagues eff ectively to best serve patients’
    interests. In this instance you should aim to get the patient referred as
    early as possible, even if this means involving the consultant. Clearly,
    speaking to the SHO directly is better than involving the consultant if
    this can be avoided, hence (D) is better than (C). Involving the nurses
    (B) requires that they become involved in a task they are not supposed
    to do, and this is therefore less preferential. However, it is better than
    (A) which leaves the task (and therefore the patient) until the end of the
    day. (E) is clearly the worst as it leaves the patient in pain for the longest
    duration.

Question 11

11. You are working in a genitourinary medicine clinic. A patient
    attends because she believes that she may have contracted an
    infection following a recent sexual encounter outside of her long-term
    relationship.
    Choose the THREE most appropriate actions to take in this situation
    A Advise her to begin contact tracing, i.e. informing her regular partner.
    B Suggest you will have to inform her long-term partner if she does not.
    C Test for HIV as HIV testing is mandatory.
    D Advise a blood test for syphilis antibody.
    E Promote safe sexual practices.
    F Discuss the morality of multiple sexual partners.
    G Inform the patient’s GP to ensure adequate community follow-up.
    H Ask a phlebotomist to draw the blood sample to avoid the risk of a
    needle-stick injury.

Answer 11

11. A, D, E
    Confi dentiality is central to the trust between patients and doctors. The
    disclosure of information in the interest of public safety is a complex
    issue, requiring a balanced and thoughtful clinical judgement in discussion
    with the patient. In this scenario, it is recommended to complete a
    sexual diseases screening to rule out common or serious infections (D),
    although no disease must be tested for (C). It would be unfair to defer
    phlebotomy to another healthcare professional (H) simply because you
    are worried. At this stage, it is not appropriate to consider disclosure of
    the patient’s sexual encounter to her partner or GP (B) (G), although she
    might be encouraged to share this information herself (A). Such clinical
    encounters provide the opportunity to promote safe sexual practices
    (E), but personal opinions about patients’ sexual practices should remain
    private (F).

Question 12

12. You have arrived on a ward to review a medical outlier. You
    retrieve the patient’s notes from the treatment room after
    several wasted minutes searching for them in the notes trolley. You
    are exasperated as you risk missing lunch, again, if not en route to the
    canteen within ten minutes. The telephone at the nurses’ station rings.
    There is no ward clerk. Although the surgical FY1 doctor and his registrar,
    a staff nurse, and a physiotherapist are standing at the desk, no one
    answers after 20 rings.
    Choose the THREE most appropriate actions to take in this situation
    A Tell the surgical FY1 doctor to answer the phone.
    B Tell the staff nurse that you are in a great hurry and that she/he
    should answer the phone.
    C Move away from the nurses’ station quickly and let the phone be
    answered by someone else.
    D Ask the staff nurse whether you can answer the phone and let her/
    him know what is needed.
    E Pick up the phone and give the handset straight to the staff nurse saying
    ‘It’s for you’.
    F Ask people at the desk whether someone is waiting for a call and
    answer the phone if no one volunteers.
    G Ask the nurse in charge whether there is a policy on answering phones
    on the ward.
    H State to all around the desk that the call might be very important for a
    relative/carer or directly related to patient care.

Answer 12

12. D, F, H
    This common scenario represents many priorities which must be balanced,
    the most important of which is patient care. Ward telephones
    should be answered promptly even if it is not an individual’s direct
    responsibility because they carry a bleep. The staff nurse may be more
    persuaded to help if you have their prior agreement (D). It might just
    be easier to answer the phone quickly, work out what the call is about,
    and move on (F). You may have unrealistically expected to see a patient
    within ten minutes as well as making it to lunch on time. It is often useful
    to lead by example, in which case simply expecting others to act may
    be unhelpful (A) (B) (C). Only if the diffi culty persists and/or this is a
    ward that you are likely to visit again should you need to fi nd out the
    policy on answering telephones (G). Giving the handset directly to the
    staff nurse (E) would be bad manners and unlikely to provoke a positive
    response, particularly as you do not know the urgency of the task he is
    currently managing. Ultimately the call might be important and should be
    answered, and although (H) is imposing and it might be diffi cult to interrupt
    others in the middle of their own jobs, it is the least worst of the
    remaining options after (D) and (F).

Question 13

13. During your fi rst month working on the neurosurgery ward,
    you have become increasingly troubled by your registrar’s ability.
    You have seen him misinterpret basic clinical signs. On one occasion
    you tried to share your concerns with the consultant in charge
    but he discounted them, highlighting the registrar’s natural ability in the
    operating room.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Ask your consultant again to consider the registrar’s overall
    performance.
    B Inform your Educational Supervisor.
    C Approach the registrar and ask him whether he would be willing to
    receive teaching from you after work.
    D Inform the Clinical Director.
    E Share your thoughts with another FY1 colleague.

Answer 13

13. A, B, D, C, E
    You must ensure patient safety by raising your concerns, and there is a
    fairly clear order of escalation. In this scenario, (A) is better than (B), as it
    is more appropriate to formally raise the issue again with the consultant
    and reiterate your concerns with specifi c examples of what you believe
    has been done incorrectly. It is possible that your assessment is inaccurate
    or disproportionate, and discussion with a senior colleague may be helpful
    in this respect. In any event, if the evidence is unequivocal, the registrar
    will benefi t from the input of a senior clinician. Informing the Clinical
    Director (D) represents a greater escalation than your Educational
    Supervisor (who is another consultant typically responsible for fewer staff
    than the clinical director). It may eventually be appropriate to inform the
    Clinical Director, although you should escalate stepwise through the local
    hierarchy. It would be ideal to approach the registrar himself; however,
    off ering him teaching is unlikely to be constructive and in this case would
    not be appropriate (C). If, however, the option was to approach the registrar
    and to discuss your concerns further with him, this would have been
    the best option. (E) is the worst option as it amounts to gossiping and will
    not lead to the problem being resolved.

Question 14

14. You are the paediatric FY1 doctor. A nurse asks if you could
    speak with the family of a 13-year-old patient, Lenka, who does
    not speak any English. Lenka’s family is very angry and they demand that
    she is moved away from the neighbouring patient who has been coughing
    vigorously throughout the night. You also notice that Lenka appears
    to be upset.
    Choose the THREE most appropriate actions to take in this situation
    A Acknowledge the family’s concern and try to move the patient into a
    side room.
    B Explain to the patient’s family the low risk of contracting an infection
    from neighbouring patients in open bays on the ward.
    C Try to establish Lenka’s concerns.
    D Try to address the concerns of Lenka’s family fi rst.
    E Ask the neighbouring patient if they would be willing to move into a
    side room.
    F Provide the patient and her family with face masks.
    G Ask the ward nurse to address these nursing concerns.
    H Provide the neighbouring patient with a face mask.

Answer 14

14. B, C, D
    Good Medical Practice reminds us to listen to patients, and to spend
    time with relatives and respond to their concerns and preferences. In
    this scenario, where the child does not speak English, you should try to
    understand the family’s particular health beliefs before communicating
    via them with Lenka to identify her concerns (C) (D). The family may
    be unsettled by conditions on the ward, but the neighbouring patient is
    unlikely to pose a risk to Lenka (B) and any patients who are at risk of
    transmitting infectious diseases would already be isolated. Therefore it is
    unnecessary and an inappropriate use of resources to isolate Lenka or
    the neighbouring patient (A) (E), or to provide face masks (F) (H). Since
    you have begun to speak to the patient’s family, and can respond to their
    concerns, it would be unfair to refer them to the ward nurse (G).

Question 15

15. You are clerking patients in the Medical Admissions Unit
    (MAU). A former colleague approaches and informs you that
    his father is one of the patients waiting to be clerked. He asks you to see
    his father fi rst.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Report your medical colleague to his Educational Supervisor.
    B Refuse your colleague’s request outright.
    C Ask the registrar whether he has any preference for which patient you
    should see next and, if not, begin with your colleague’s father.
    D See your colleague’s father last, as punishment for his unfair request.
    E Establish if there is any particular reason why he wants you to see his
    father straight away.

Answer 15

15. E, B, C, A, D
    The GMC requires doctors to treat patients fairly and not to discriminate
    unfairly between them. In this instance, your colleague may be
    abusing his position to gain preferential treatment, but it is possible that
    his professional insight has raised a concern which should expedite his
    father’s care. For this reason (E) is the best option.
    (B) and (C) are diffi cult to choose between and will depend on several
    factors not discussed, e.g. the department or other patients. It is important
    to weight fairness against working with colleagues, and your registrar
    may be able to off er additional insight and help triage the patients
    waiting to be clerked (however, this requires involving a likely very busy
    registrar with a query that is questionable at best). On balance most
    doctors would say it is better to decline your former colleague’s request
    if there is no good reason. (A) is unfair and excessive, while (D) is all of
    the above and dangerous, and is clearly the worst option.

Question 16

16. Lucy is a 24-year-old with Crohn’s disease. On reviewing her
    drug chart, you fi nd that multiple doses of medication have
    not been given. On questioning the nurse who has been looking after
    Lucy since her admission, she says that the patient has been refusing to
    take the medication when off ered. However, you have always found the
    patient to be pleasant and cooperative. Lucy denies being off ered any
    medication by the nurse.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Report the nurse to the Royal College of Nursing.
    B File a clinical incident form for failing to satisfactorily encourage Lucy
    to take her medication.
    C Suggest that the nurse sits with Lucy and encourages her to take her
    medication.
    D Change all her medication to intravenous forms.
    E Inform the Ward Sister that Lucy has not been receiving her medications,
    and ask her to investigate further.

Answer 16

16. E, B, C, A, D
    Failing to give Lucy her medications could put her at unacceptable risk.
    There is a suggestion that the nurse has neglected an important duty, and
    the Ward Sister should be requested to investigate the matter further,
    hence (E) is the best option. (C) also raises the concern with nursing
    staff , but only with the nurse involved, and would address the matter if
    the problem was patient compliance but not if there was an issue with
    the nurse’s dispensing of medication. (B) does not resolve the situation
    immediately but goes about initiating the same processes that the Ward
    Sister would begin in (E) therefore (B) can be justifi ed as being better
    than (C). (A) is incorrect without further corroboration/information.
    (D) does not adequately address the failure by the nurse or the patient’s
    non-compliance for the future and is potentially dangerous, introducing
    unnecessary risk to the patient.

Question 17

17. Mr Stevenson has recently been diagnosed with terminal mesothelioma.
    During his admission for a chest infection, you are
    handed an indefi nite DNACPR (Do Not Attempt Cardio-Pulmonary
    Resuscitation) order that has been in place since a previous admission.
    On speaking to Mr Stevenson and his family, they do not appear to be
    aware that this order is in place.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Tear up the DNACPR order.
    B Explain the futility of cardiopulmonary resuscitation in Mr Stevenson’s
    case as the logic of the DNACPR order.
    C Apologize for the insuffi cient explanation given by Mr Stevenson’s
    previous clinicians.
    D Inform your registrar immediately.
    E Do not inform Mr Stevenson and his family about the DNACPR order
    at this time, but wait to discuss the matter with Mr Stevenson alone.

Answer 17

17. E, D, B, C, A
    It is essential that there is adequate communication between the patient
    and the clinical team. The revelation that Mr Stevenson and his family do
    not know about the DNACPR order warrants a discussion with your
    senior, but the scenario does not imply any immediate imminent danger,
    hence this is not immediately necessary. (E) would therefore be preferable
    to (D) as it allows you to establish what the patient has already discussed
    (perhaps in private away from his family), and discuss the matter
    with your seniors further if necessary. (B) is probably not a discussion
    that should be undertaken by a FY1 doctor, particularly if the issue had
    never been raised before. (C) is the fi rst wrong answer as you cannot
    apologize for colleagues and do not know what he was previously told
    and why. (A) is the worst answer as you do not know why the DNACPR
    was put in place, or by whom, and you are not in a good position to
    make DNACPR decisions.

Question 18

18. You are taking a history from the mother of 11-year-old Clara
    who has presented with shoulder pain. When you are left alone
    with Clara, she admits that her mother often gets upset with her and has
    occasionally hit her in the past. The mother has appeared completely
    appropriate in her interaction with Clara.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Clara is most likely referring to reasonable chastisement, and the issue
    should not be pursued.
    B Confront Clara’s mother about the accusation, and ask her to volunteer
    any explanations.
    C Document the comments clearly, and attempt to gain more information
    from Clara, alone if possible.
    D Begin a thorough head-to-toe examination of Clara once her mother
    has returned and, if asked, explain that you are looking for bruises.
    E Inform the police.

Answer 18

18. C, D, B, E, A
    Although Clara’s description may represent reasonable chastisement,
    the issue should be explored as it might indicate non-accidental injury.
    (C) is the best option as it ensures the comments have been recorded
    and allows further detail to be established which may clarify what she
    means, or else highlight further concerns which can then be shared
    with an appropriate senior colleague. Accurate contemporaneous
    documentation is always key, and such cases might be followed up by
    external agencies and your information relied upon in court. (D) is not
    ideal and risks antagonizing the mother if she probes further, but it is
    important to assess the patient, and in this instance your honesty would
    not be unacceptable. (B) would generally be considered incorrect for an
    FY1 doctor to undertake independently and is therefore worse. (E) is a
    disproportionate and excessive response that is by no means justifi ed
    at this stage, although it is marginally better than (A) which completely
    ignores the potential seriousness of Clara’s disclosure.

Question 19

19. You are about to discharge Terence following his admission
    for treatment for recurrent epileptic seizures. On getting up to
    leave the bedside, you overhear his wife’s surprise at the doctors allowing
    him to return to work as a heavy goods vehicle driver. You feel sure
    that Terence has no intention of relinquishing his driving responsibilities,
    despite promises to the contrary.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Seek assurances from Terence’s wife that he will not return to work.
    B Inform Terence’s GP.
    C Ask Terence to sign an agreement not to return to work in the
    medical notes.
    D Disclose his diagnosis to the Driver and Vehicle Licensing Agency
    (DVLA).
    E You are not responsible for the patient’s actions once you have
    appropriately instructed him.

Answer 19

19. D, B, A, C, E
    Although confi dentiality is necessary to maintain patient trust in doctors,
    it may be breached to protect others from serious harm. Terence has a
    legal duty to inform the DVLA, which is likely to ask him to surrender his
    licence. The best answer would be to encourage the patient to disclose
    his disability and, failing this, to do so yourself. (D) represents the safest
    option available and is therefore the best option. The remaining options
    are generally inappropriate. (B) at least informs another colleague that
    there is an issue, who could follow the issue up further. (A) is worse
    as the wife might not be trusted, given her confl ict of interest, and this
    represents an unfair burden as she might not be able to control her husband,
    although there is a possibility she would be able to prevent him
    from driving. (C) is tantamount to doing nothing, and adds nothing on
    top of a verbal reassurance. (E) is obviously wrong and neglects a duty
    to protect public safety.

Question 20

20. A 40-year-old mother of two children stops you as you are
    walking by her side room and asks to speak with you. She is visibly
    worried about the results of her pancreatic biopsy and asks, ‘What
    will happen if I have cancer?’
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Reassure the patient that the medical team will do everything they can
    to try to treat her.
    B Reassure her that everything will be fi ne.
    C Ask the patient to wait and ask your senior any questions.
    D Echo her concern: ‘I can see that you are worried that you might have
    cancer.’
    E Do not say anything, but instead look away in an eff ort to communicate
    the grave nature of her problem non-verbally.

Answer 20

20. A, D, C, B, E
    It is often necessary to strike a careful balance between reassurance and
    fostering a realistic outlook that does not compromise the patient’s faith
    in the profession. At this stage you cannot fully reassure the patient,
    and instead must be honest about her situation (A). (D) is the next best
    answer; although it would be odd and unlikely to help the patient, it is a
    neutral statement. (C) is worse as it burdens your seniors unnecessarily,
    particularly since the patient has not asked for any specifi c information. It
    is diffi cult to discriminate between the last two options. (B) is incorrect,
    and (E) is ambiguous, confusing, and unfair to the patient. The implication
    of a poor outcome without explicitly stating so is perhaps worse
    than a falsely reassuring comment made in passing.

Question 21

21. Iris is 87 and one of your patients on the care of the elderly
    ward. She has mild dementia but tells you that she doesn’t like
    being dressed by the nursing staff each morning. At home, her carer just
    stands by in case she needs help, although she concedes that this ‘takes
    longer’ than allowing the carer to dress her.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Tell Iris that as soon as she goes home she’ll be able to go back to her
    old routine.
    B Tell Iris that she can dress herself each morning if she prefers, with
    help if necessary.
    C Pass on Iris’s request to the Ward Sister and ask that it be passed on
    during the nursing handover.
    D Explain that this is probably not possible as the nursing staff are busiest
    in the mornings.
    E Tell Iris that you can’t interfere with how the ward is run.

Answer 21

21. C, B, A, D, E
    All healthcare professionals should respect patient autonomy and
    empower patients as far as possible. It is better to speak to the nurses
    before promising anything directly to the patient; therefore (C) is a better
    option than (B). It is unfair not to pass on the patient’s (reasonable)
    request to the nursing staff ; therefore the remaining answers are incorrect.
    (A) is probably the better of those remaining, as it might be good
    for the patient’s morale. (D) is less eff ective than (A) as it fails to address
    the problem and represents a less positive, more neutral statement.
    (E) has the same failings as (D), possibly carrying a more negative undertone,
    but more importantly is factually incorrect.

Question 22

22. You are asked by the nurses to site a urethral catheter for Arthur
    who is an elderly man who needs to urinate frequently. He has
    known prostate trouble and reduced mobility. It takes at least fi ve minutes to
    get him to the toilet, after which he often does not need to urinate after all.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Ask Arthur for his views and whether he is troubled about multiple
    visits to the toilet.
    B Off er other options such as a commode or a male external catheter.
    C Speak to the urology team to ask if there is anything further that can
    be done to minimize Arthur’s lower urinary tract symptoms.
    D Explain the problem to Arthur and then insert a urethral catheter
    once he consents.
    E Tell Arthur that he needs a urethral catheter and then site it carefully.

Answer 22

22. A, B, C, D, E
    You should only off er invasive treatment if it is in the patient’s interest
    and you have consent. (A) is the most patient-focused response and will
    help guide you to the correct management for the patient. (B) is less
    eff ective as it fails to establish a history and the patient’s perspective
    about his symptoms, although he is involved in the decision-making, and the options off ered are less invasive. (C) is likely to be unnecessary in
    this case, but it is not harmful, although it may delay a speedier resolution
    which could be achieved without having to involve another specialist
    team. (D) is less eff ective than (C) as it is mildly harmful to insert a catheter,
    but it is done correctly by explaining the procedure and obtaining
    consent. For this reason (D) is better than (E), as the consent obtained
    with this option (E) is somewhat dubious.

Question 23

23. You arrive on the ward one morning to fi nd a student nurse
    washing a male patient with the curtains open. The patient does
    not appear to be obviously concerned.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Pull the curtains closed.
    B Ask the patient for his preference and leave the curtains open if he
    chooses.
    C Explain the need to ensure patient privacy to the student nurse afterwards
    if she is unclear.
    D Tell the student nurse in front of the patient that she should learn to
    respect privacy.
    E Carry on with your job as there is not a problem and you shouldn’t
    interfere.

Answer 23

23. A, C, D, E, B
    You should take steps to protect patient dignity whenever possible.
    (A) is the most immediate way to achieve this. (C) is a less immediate
    action but still off ers a sensible approach. (D) is unprofessional as it
    undermines your nursing colleague, but it is not completely incorrect as
    the underlying issue is still addressed. For this reason, (D) is better than
    (E) as ignoring the issue is slightly worse. Patient choice is important, but
    other patients and visitors to the ward need to be considered as well,
    and it would be considered poor judgement to attempt to address the
    issue only to go on and leave the curtains open (B).

Question 24

24. You are on a fast-paced surgical ward round. Your consultant tells
    a patient that she will need a ‘Hartmann’s procedure which will
    leave a colostomy’ and she signs a consent form. You can tell from her body
    language that she wants to ask questions but does not feel able to do so.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Explain that you will come back after the ward round in case she
    wants to ask any more questions.
    B Insist that the consultant stays until he has answered her questions.
    C Tell the patient that your consultant will come back later to answer
    questions.
    D Let the ward round continue but remain behind to draw a picture for
    the patient illustrating Hartmann’s procedure.
    E Continue with the ward round but return later to answer questions.

Answer 24

24. A, E, D, B, C
    It is important that patients have an opportunity to ask questions, particularly
    about such an important issue. In this case, indicating to the
    patient that you will come back addresses the main issue raised in the
    question, without disrupting the ward round, and is the best answer (A).
    This is preferable to simply going back later (E), as it will reassure the
    patient immediately to know there will be an additional opportunity to
    ask further questions, although (E) does still deal with the underlying
    issue. (D) is good for the patient but inevitably disrupts the ward round
    and is therefore less preferable. (B) is worse than (D) as it is unprofessional
    and causes maximum disruption to the rest of the ward round.
    (B) and (C) are diffi cult to discriminate, and arguments can be made for
    both being the worst answer. One can argue that (B) carries a greater
    risk of jeopardizing your professional relationship with the consultant by
    insisting on his cooperation in front of the patient, compared to falsely
    promising a meeting with the consultant (C) (a meeting that you might be
    able to eff ectively negotiate more politely than is implied in option (B)).
    They are both unprofessional, but for the patient (C) is worse as you
    cannot guarantee that the consultant will return, and this risks leaving the
    patient’s questions entirely unanswered.

Question 25

25. As you are sitting at the nurses’ station completing a discharge
    summary, you see a 55-year-old patient walking away from you
    with his gown fl apping open at the back.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Shout to the patient by name so that he can be alerted to his state of
    undress.
    B Catch up with the patient and let him know that he is partially
    undressed.
    C Help him tie up the gown correctly.
    D Find a nurse and let them know the patient needs assistance.
    E Catch up with the patient and tell him that he should be more careful
    in case he embarrasses other patients or visitors.

Answer 25

25. B, C, D, E, A
    You should take action as necessary to protect patient dignity. In this
    case, (B) is the most helpful and polite response. (C) is a reasonable
    action, but it would be preferable to speak to him as in (B) fi rst. It would
    be better to deal with the patient’s immediate (and easily correctable,
    be it non-life-threatening) problem yourself and avoid delay, rather than
    seeking a nurse (D). The two remaining options are incorrect, with
    (A) being impolite and (E) being even more unkind by blaming the patient
    for a genuine mistake.

Question 26

26. Your Trust occasionally authorizes use of protective mittens for
    certain patients. These are large gloves that essentially prevent
    patients from using their hands. You are asked to prescribe mittens for a
    patient out of hours and agree to do so only under specifi c conditions.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A The patient is confused.
    B The patient lacks capacity.
    C The patient lacks capacity and is at risk of pulling out essential lines
    and tubes.
    D The patient lacks capacity and has pulled out lines and tubes, and
    alternative strategies have been unsuccessful.
    E The patient lacks capacity and is at risk of pulling out essential lines
    and tubes. The patient’s next of kin are fi ercely opposed to the use of
    mittens.

Answer 26

26. D, E, C, B, A
    Mittens risk causing patients signifi cant distress and should only be used
    in limited circumstances. Most Trusts have strict criteria and rules for
    their use, for example: the patient should either consent or lack capacity,
    and had previously pulled out lines and tubes, and alternative strategies
    have been unsuccessful. Hence (D) is the correct answer. The hostile
    family members are likely to dissuade you from the use of mittens, but
    cooperation is not a requirement and therefore (E) is an appropriate
    (albeit less ideal) response. (C) represents a partial requirement, whilst
    (B) is even less appropriate as it represents less fulfi lment of the required
    conditions for using mittens. (A) is not really necessary even for the use
    of mittens, and is therefore the worst answer.

Question 27

27. A patient admitted to your ward with pneumonia is shown to
    have tuberculosis (TB). He is asked to wear a face mask when he
    leaves his side room and told that the case must be reported to the Health
    Protection Agency. He refuses to allow information about his illness to be
    sent externally and is often seen outside his side room without a mask.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Explore the reasons for this patient’s non-compliance.
    B Explain that TB is potentially dangerous and very easily spread to others
    in the hospital.
    C Explain that you will not send his details externally but that his GP
    must be informed.
    D Explain to the patient but submit his details to the Health Protection
    Agency (HPA), regardless of whether he gives consent.
    E Discharge the patient from hospital without further treatment as he is
    a danger to other patients.

Answer 27

27. B, D, A, C, E
    (B) is the best answer as it is most likely to resolve the problem and
    off ers appropriate counselling to the patient. It is obviously preferable to
    resolve the problem with the patient and obtain his consent for sharing
    information with the HPA, but telling the patient that you will be informing
    them is a fair and reasonable response (D). However, (D) is not as
    eff ective as (B) as the immediate risk to other people is minimized by
    explaining the seriousness of the condition and why the restrictions are
    being imposed on him. While you should generally explore all reasons
    for non-compliance (as patients might be amenable to persuasion), you
    are unlikely to impart the essential information that he has a communicable
    disease which might currently risk others, and that this should be
    reported to the HPA (A). (C) is incorrect as the HPA must be informed,
    while (E) is both incorrect and represents a failure to treat the patient,
    putting him and others at considerable risk from untreated tuberculosis.

Question 28

28. Ron is an elderly man with bowel obstruction. He is delirious
    and keeps pulling out intravenous cannulas as well as occasionally
    tugging on his nasogastric tube. Reinserting cannulas is becoming
    increasingly time-consuming and he is running out of suitable veins.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Resite cannulas in areas less likely to be disrupted (e.g. feet).
    B Prescribe gloves/mittens according to hospital policy.
    C Try taping and bandaging tubes for additional security.
    D Ask whether a ‘special’ nurse can be assigned for one-to-one care.
    E Tape incontinence pads around Ron’s hands to stop him pulling
    out lines.

Answer 28

28. C, A, D, B, E
    Ron may cause himself considerable harm by inadvertently pulling out
    lines and tubes. You should ensure Ron’s safety using the minimum
    amount of restrictions. The order of answers suggested here is an
    appropriate order of escalation and so almost by defi nition the next
    stage is ‘less appropriate’ than the one before. Bandages (C) are less
    invasive than resiting cannulas (A), while specialist one-to-one nursing
    (D) might be able to obviate the more restrictive option which is often
    a last resort—mittens (B). Mittens should only be used as a last resort
    when other strategies have failed and according to Trust policy. Taping
    pads to Ron’s hands would be undignifi ed and uncomfortable, and may
    worsen his agitation (E). If hands must be constrained, specially designed
    mittens should be used according to policy.

Question 29

29. Ivy has dementia and often screams out all night. Her clinical
    condition has recently improved and she has become mobile
    by ‘furniture walking’ around the ward. She is violent and abusive when
    stopped by members of staff .
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Try to reason with Ivy, explaining as far as possible that it is unsafe for
    her to move around the ward.
    B Suggest distracting interventions, such as playing music.
    C Prescribe ‘as required’ (PRN) sedation.
    D Ask whether a ‘special’ nurse can be assigned for one-to-one care.
    E Prescribe sedation when Ivy becomes particularly agitated and endangers
    herself or others.

Answer 29

29. A, B, D, E, C
    The correct order of answers here represents a clear order of escalation,
    beginning with the more conservative least invasive methods fi rst.
    Sedation should only be prescribed when it is in your patient’s interests The interests of colleagues and other patients are secondary in this case.
    Although Ivy has dementia, attempts should be made to explain to her
    that she is unsafe to mobilize (A). Other alternatives to sedation can
    then be explored, such as distraction (B). One-to-one nursing might be
    required and may be successful, but it is obviously resource intensive and
    this needs to be considered (D). Sedation may be considered when Ivy
    becomes particularly agitated and a risk to herself (E), although prescribing
    the medication when necessary would be favoured over ‘PRN’ sedation
    (C) to avoid the patient being oversedated by nursing staff .

Question 30

30. You are hoping to fi nish your ward round quickly before meeting
    your Educational Supervisor an hour later. You see Rose,
    who is very overweight and disabled with osteoarthritis, sitting in a chair.
    You are told that she developed severe abdominal pain overnight and so
    will need to be examined in bed. This will require considerable time as
    she must be hoisted.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Ask the nursing staff if they can help Rose into bed while you see
    other patients fi rst.
    B Ask Rose whether she would mind lying in bed so that you can examine
    her thoroughly.
    C See Rose later as you are pressed for time.
    D See Rose now but feel her abdomen while she is sitting in the chair
    instead.
    E Go to your meeting with a view to assessing Rose afterwards.

Answer 30

30. B, A, D, E, C
    Patient care must be prioritized, even above educational commitments.
    The concern is that Rose has a possible acute abdomen and therefore
    needs to be examined properly. The best answer is (B) which informs
    her about your intentions and is clearly a better use of resources than
    (A). Both options are, however, preferable to conducting an inadequate
    examination of a patient who has potentially become very unwell (D).
    (E) and (C) are the worst answers as they both neglect any assessment
    of Rose. (E) is only marginally better as you are at least making an eff ort
    to attend your meeting.

Question 31

31. Flora is 73 and suff ering from hospital-acquired pneumonia.
    She has been receiving intravenous antibiotics, but is no longer
    confused and is becoming unhappy with your continued attempts at
    cannulation.
    Choose the THREE most appropriate actions to take in this situation
    A Tell Flora that she will probably die without intravenous antibiotics.
    B Stop the antibiotics and resite the cannula if Flora deteriorates
    without them.
    C Prescribe oral antibiotics and document clearly that Flora refused
    cannulation.
    D Off er to ask a colleague to try if the next attempt fails.
    E Explain carefully why a cannula is necessary.
    F Tell Flora that the next attempt will be successful.
    G Persist with cannulation attempts as Flora does not have capacity.
    H Consider whether antibiotics can be de-escalated to oral equivalents

Answer 31

31. D, E, H
    Competent adults can refuse any treatment, including cannulation.
    However, you have a duty to ensure that they understand the reason
    it is necessary and the likely consequences of refusal (E). This might be
    an appropriate time to consider converting to oral antibiotics (H) or a
    compromise might be necessary, such as off ering to seek help from a colleague
    after another attempt (D). You should not accept Flora’s refusal
    of further attempts without clear discussion of the need for intravenous
    antibiotics (C). This discussion should be realistic and not calculated to
    coerce the patient (A). You cannot guarantee that the next attempt will
    be successful (F) and there is no reason to think that Flora does not
    have capacity (G). Antibiotics should not be stopped in their entirety
    (B) simply because Flora is declining cannulation—oral equivalents may
    confer some benefi t.

Question 32

32. Randhir is 50 and was admitted under the orthopaedic team
    with severe back pain. MRI shows only degenerative change.
    Your consultant says that the patient cannot be kept in hospital ‘forever’
    because of pain and should be discharged with spine surgeon follow-up.
    The patient and his family do not believe that he can go home because
    he cannot work and is in severe pain.
    Choose the THREE most appropriate actions to take in this situation
    A Delete the patient from your list so that he can stay in hospital for a
    few more days without your consultant knowing.
    B Explore Randhir’s concerns about going home.
    C Promise that you will ensure that the back pain appointment is made
    within two weeks.
    D Tell Randhir that the bed is needed for more urgent cases.
    E Carefully explain the nature of mechanical back pain.
    F Ensure that the pain team is involved with discharge planning so that
    appropriate analgesia can be provided in the community.
    G Prescribe ‘as required’ (PRN) oral morphine until the patient is
    discharged.
    H Tell Randhir he needs to learn to accept the pain as there may be
    nothing that can be done to help.

Answer 32

32. B, E, F
    Compromise is always preferable and can only be achieved by understanding
    Randhir’s concerns (B) and clarifying any misunderstandings
    (E). Regardless of confl ict persisting, the discharge should be managed
    like any other with eff ective analgesia and follow-up (F). You should not
    make unhelpful statements, for example that nothing can be done to
    help (H) or that the bed is needed for ‘more urgent’ cases (D).
    You should never mislead your consultant over which patients are
    under their care (A). It is unlikely that you can guarantee the timescale
    on which outpatient appointments are made (C). Regular strong opiate
    analgesia may be unhelpful if this cannot be continued in the community
    (G). This strategy should only be considered on specialist advice.

Question 33

33. Archie is a 70-year-old man admitted six days previously for an
    acute coronary syndrome. He has always been polite and pleasant
    to speak to. However, today he seems unwilling to answer questions
    directly and you fi nd yourself becoming increasingly annoyed about having
    to repeat every question to keep him on track.
    Choose the THREE most appropriate actions to take in this situation
    A Calculate an Abbreviated Mental Test Score (AMTS).
    B Tell Archie that you will come back later after you have seen some
    other patients.
    C Document in the notes that Archie is a ‘diffi cult patient’.
    D Consider requesting blood tests, urinalysis, and a chest X-ray.
    E Just ‘eyeball’ Archie the following day rather than seeing him thoroughly
    on the ward round as this took a long time the day before.
    F Take a full history and examine Archie, even if it is taking longer
    than usual.
    G Ask your consultant if Archie can be discharged soon as he seems to
    be fed up with being in hospital.
    H Move on quickly so that you can continue the ward round.

Answer 33

33. A, D, F
    It is important not to let feelings cloud your professional judgement. The
    concern here is that Archie has become confused, which might be apparent
    objectively on calculating his AMTS (A). Otherwise unexplained personality
    changes warrant a full history, examination (F), and septic screen (D).
    Your personal feelings should not cause you to move on prematurely
    (B) (H) or avoid seeing Archie (E) the following day. Documenting that
    Archie is a ‘diffi cult patient’ (C) adds little to his care. Conspiring to promote
    an early discharge is also unhelpful if Archie’s personality change is
    the result of a pathological event (G).

Question 34

34. The nurses inform you that one of your patients has died. He
    had metastatic lung cancer and had been ‘do not resuscitate’ for
    weeks. As you arrive at the patient’s side room to confi rm death, you
    are aware that the patient’s family are all present, having been called by
    the Ward Sister.
    Choose the THREE most appropriate actions to take in this situation
    A Go straight into the room in case another FY1 doctor gets there fi rst.
    B Explain why you have arrived and what you intend to do.
    C Ask the relatives to leave as there is a bed crisis and the patient has to
    be moved to the mortuary.
    D Ask everyone present for identifi cation to prove they are close
    relatives.
    E Give the relatives some space and come back later, introducing yourself
    if they are still there.
    F Tell the relatives this is probably what the patient ‘would have
    wanted’.
    G Let the relatives choose whether to be in the room or outside while
    you confi rm death.
    H Enter the room and commence chest compressions if the patient is
    pulseless.

Answer 34

34. B, E, G
    Although formal confi rmation of death should be done promptly, other
    considerations may be prioritized. The relatives may appreciate some
    time with the patient, after which you should introduce yourself (E) and
    explain what the process involves (B). You should let the relatives
    choose whether to vacate the room (G), as some aspects (e.g. checking
    for pupillary refl exes) might distress them.
    There is no need to ask for identifi cation (D), make trite comments
    which may cause off ence (F), or commence chest compressions (H) if
    there is a valid ‘do not resuscitate’ instruction. Financial (A) and bed management
    considerations (C) have no place at this time.

Question 35

35. Mike is an intravenous drug user on the gastroenterology ward
    with liver failure secondary to hepatitis C. He is currently prescribed
    intravenous methadone, but healthcare staff are struggling to
    administer this as his veins are overused. He wants to inject his own
    methadone as he would do at home.
    Choose the THREE most appropriate actions to take in this situation
    A Discuss with the Ward Sister as to whether self-injecting is acceptable
    on the ward.
    B Explain that it is never acceptable for patients to administer their own
    medication.
    C Ensure that Mike is familiar with the NHS equipment and safety rules
    (e.g. sharps disposal).
    D Off er Mike oral morphine if he agrees to forgo methadone injections.
    E Only agree if the procedure is supervised by a member of staff .
    F Explain that this is not possible as he is hepatitis C positive.
    G Give Mike a supply of needles and tell him to ‘make himself at home’.
    H Ask Mike what dose of methadone he usually takes and prescribe this
    amount.

Answer 35

35. A, C, E
    Any decisions about behaviour on the ward should be made in
    collaboration with the nursing staff (A). If it is agreed that Mike can
    administer his own methadone, he must be familiar with the equipment
    and safety requirements (C), and supervised (E) to ensure that sharps
    are appropriately discarded.
    It would be inadvisable to alter Mike’s regimen (D) without specialist
    advice or to give him needles (G) without addressing the issues above.
    Patients are often allowed to administer their own medication (B) (e.g.
    self-injecting insulin) when this is agreed with the nursing staff .
    Hepatitis C emphasizes the importance of disposing of sharps safely
    but does not alter whether the process of self-injecting is permissible
    (F). Doctors should not usually accept the dose of methadone
    that someone who is drug-dependent has said they are usually prescribed
    (H). Independent verifi cation is necessary (e.g. from a GP or
    pharmacy).

Question 36

36. Roger was admitted to your ward following a stroke which
    has left him with severe weakness down his left side. He was
    referred to a local rehabilitation hospital three weeks ago and is currently
    waiting for a bed to become available.
    Choose the THREE most appropriate actions to take in this situation
    A Ask the ward physiotherapists if they could spend extra time with
    Roger before a rehabilitation bed becomes available.
    B Ensure that daily infl ammatory markers are sent in case Roger develops
    hospital-acquired pneumonia.
    C Call the rehabilitation hospital and insist that they fi nd a bed as Roger
    is at risk of complications (e.g. pressure sores).
    D Cross off the routine prescription for daily low molecular weight
    heparin to reduce the number of injections he receives.
    E Call the rehabilitation hospital to check Roger’s position on the waiting
    list and ensure that they know that he has waited for three weeks.
    F Keep Roger informed of his progress up the waiting list.
    G Discharge Roger home to bypass the rehabilitation hospital.
    H Suggest that Roger’s family keep calling the rehabilitation hospital to
    push his name further up the waiting list.

Answer 36

36. A, E, F
    Doctors must advocate appropriately for their patients. If the wait is
    unusual, you should contact the rehabilitation hospital to check that
    Roger has not been missed (E). You should keep Roger informed (F) and
    ask the ward physiotherapists to do their best to mitigate the disadvantage
    of remaining in an acute hospital bed (A).However, you should be sensitive to the resource allocations of other
    healthcare providers. Asking Roger’s family to campaign (H) at the
    expense of other patients or insisting that the rehabilitation hospital fi nd
    a bed (C) may be unhelpful. Daily infl ammatory markers are inappropriate
    in a ‘well’ patient (B), but low molecular weight heparin should probably
    continue as his mobility is impaired (D). Discharge would only be
    appropriate if the multi-disciplinary team agree that Roger has returned
    to baseline and no longer requires prolonged rehabilitation (G).

Question 37

37. Tom is a bus driver admitted with an epileptiform seizure. Your
    consultant tells Tom that he must inform the DVLA. Later in the
    day, Tom says that he can’t tell the DVLA as driving is his job and he has
    never had a seizure before this one.
    Choose the THREE most appropriate actions to take in this situation
    A Call his employer anonymously to let them know he is unsafe to drive.
    B Tell Tom that you must inform his employer and call them even if he
    refuses consent.
    C Document clearly any driving advice given to Tom.
    D Agree that he is probably not a danger but tell Tom that he should
    probably let the DVLA know anyway.
    E Call the DVLA anonymously but keep this from Tom so that your
    relationship is not disrupted.
    F Explain that there is a reasonable possibility of a second seizure.
    G Ask Tom’s wife to bring in his driving licence and surrender this to the
    Ward Sister.
    H Explain that you will have to contact the DVLA if he refuses

Answer 37

37. C, F, H
    Tom has a legal duty to inform the DVLA. Although this legal duty does
    not extend to doctors, you have a professional duty to balance the need
    for confi dentiality against harm occurring to others. Therefore you cannot
    conspire with Tom to keep his driving secret (D).
    You should ensure that Tom is fully informed about the risk of a second
    seizure (F) and that this advice is documented carefully (C). Your
    professional duty probably requires informing the DVLA if Tom refuses
    (H), but this should be made clear to him (E). Although it could be justifi -
    able to inform Tom’s employer, this is a more radical step and probably
    unnecessary if the DVLA is notifi ed (B) (A). The hospital has no role to
    play in confi scating Tom’s driving licence (G).

Question 38

38. A staff nurse approaches you with concerns about Mark, a
    young man with a recently repaired femoral fracture. He insists
    on wearing his own clothes and will not change into a hospital gown.
    Friends also bring food in for him (e.g. take-away curries), which upsets
    other patients.
    Choose the THREE most appropriate actions to take in this situation
    A Ask Mark to change into a gown because otherwise he is diffi cult to
    examine.
    B Tell the nurse that there is no good reason why Mark shouldn’t wear
    his own clothes.
    C Explain to the nurse that Mark should be able to eat food from outside
    if he prefers.
    D Tell Mark that if he is well enough to eat curry then he is well enough
    to be discharged.
    E Tell the nurse that the other patients should ask their friends/relatives
    to bring in food if that’s what they want.
    F Ask Mark to consider other patients having to eat hospital food
    before choosing food for his friends to bring.
    G Suggest that Mark be swapped with another patient who is currently
    in a side room with diarrhoea and vomiting.
    H Tell the nurse that Sister controls the ward and that she should speak
    to Mark if there is a problem.

Answer 38

38. B, C, F
    There is no obvious reason why Mark should wear a hospital gown
    (B) (A) and he certainly cannot be forced to wear one. Similarly, there
    is no clinical reason why Mark should be confi ned to hospital food (C).
    However, if this is having a negative impact on other patients, it may be
    worth bringing this to Mark’s attention (F). Although the Ward Sister
    might want to talk to Mark, there is no reason why you shouldn’t do
    so (H).
    It cannot be assumed that all patients have people willing to bring them
    food (E) and neither does it follow that Mark must be fi t enough for discharge
    (D). Moving Mark to a side room is a possibility, but only if one is
    available. He should certainly not be swapped for a patient isolated for
    clinical reasons (e.g. diarrhoea and vomiting) (G).

Question 39

39. You are asked to site a cannula in John, a patient with traumatic
    brain injury and a permanent GCS of 8. He is dehydrated and
    requires intravenous fl uid.
    Choose the THREE most appropriate actions to take in this situation
    A Explain to the patient what you are going to do.
    B Aim blind if you can’t see a target vein as multiple attempts are
    unlikely to cause pain.
    C Ask a medical student to insert the cannula as he can try a few times
    and it will be good practice.
    D Defer the job until later as it is uncomfortable being in the room with
    someone who is unresponsive.
    E Omit washing your hands and cleaning the area as the patient is
    unlikely to comment.
    F Warn the patient about a ‘sharp scratch’ as you would for any other.
    G Explain to the patient why a cannula is necessary.
    H Try to give oral fl uid instead to see if this is tolerated.

Answer 39

39. A, F, G
    Although the patient has a GCS of 8, it is impossible to know to what
    extent he is aware of his surroundings. Therefore you should assume
    that he can hear and understand. You should explain the procedure fully
    (A) (G) and give warnings when appropriate (F).
    You should not treat John diff erently because he is unresponsive, for
    example by careless attempts at cannulation (B), omission of important
    steps (E), or delegating the task inappropriately (C). John is a vulnerable
    patient as he cannot advocate for himself and so his care should not be
    deferred until later (D). Giving oral fl uid to an unresponsive patient is
    likely to result in aspiration (H).

Question 40

40. You are on your way to the blood gas analyser with a sample
    which shouldn’t be left out for more than ten minutes.
    You hear a patient shouting and put your head around the curtain. An
    elderly patient of the opposite sex you haven’t met before says they
    have been sitting on the commode for half an hour and shouting to be
    helped into bed.
    Choose the THREE most appropriate actions to take in this situation
    A Tell the patient you are in a hurry.
    B Tell the patient you are in a hurry but will come back in ten minutes.
    C Off er to help if you can without compromising the sample.
    D Say you will let a nurse know that they need help.
    E Reassure the patient that someone will probably come to their
    assistance soon.
    F Suggest that the patient pulls the emergency bell to attract the nurses’
    attention.
    G Say you are sorry that they have been there for so long.
    H Tell the patient that they shouldn’t shout unless there is an emergency
    as they may alarm other patients.

Answer 40

40. C, D, G
    In this scenario you must balance the dignity and comfort of one patient
    against the need to take a second blood sample from another. You
    should certainly help the patient on the commode if you are able (C) or
    ask a nurse to do so (D). Clearly, it is not appropriate for a patient to
    be left on the commode shouting and it is likely the nurses are occupied
    elsewhere. You could apologize for this without the need to assign blame
    (G). Clearly, reprimanding the patient for shouting is not helpful (H).
    Letting the patient know that you are in a hurry is only helpful if it
    precedes your assurance that someone else will help shortly (A) (B).
    A vague reassurance that ‘someone’ will ‘probably’ help soon is unhelpful
    (E). The patient should not be encouraged to abuse their emergency
    bell (F).