SJT At A Glance Practice Paper Flashcards

Question

25. You are an FY1 working on a labour ward. One of your patients has a breech presentation. She has a birth plan which specifies that every appropriate method should be attempted before opting for a Caesarean section (CS). She has now changed her mind and decided to have a CS. Her husband disagrees; taking you to one side and saying “she’s in pain, she doesn’t know what she wants, she’ll regret it if you operate”. What should you do? Rank the following responses from most appropriate (=1) to least appropriate (=5): A. Inform her of the overall risks and benefits of a CS and vaginal birth B. Call the consultant obstetrician to review the patient C. Enquire into her reasons for the change in birth plan D. Tell the husband you accept his point and remind him that it is his wife’s choice not his E. Ask the husband to leave so that you can speak to your patient in private

Answer 1

ANSWER: DCBAE This question is about managing contrasting views of patients and their relatives, necessitating good communication skills. An FY1 is expected to adapt their style of communication according to the context. D. Reminding him that this is his wife’s choice is the most appropriate option. You should respect the opinions of relatives, but, at the end of the day, decisions about treatment should always be made by the patient (provided they have capacity). C. Enquiring into her reasons for the change in birth plan is the next most appropriate option. You can then communicate this to your consultant. It is best practice to get as much information on the case before seeking senior advice. B. Calling the consultant obstetrician to review the patient is the next most appropriate option, as this is a decision above your level; hence you need help. The situation is relatively urgent given the potential risk to the mother and the unborn child. The consultant will also be able to advise you on how to best proceed with management in the interim. A. Informing the patient about a CS and vaginal birth is the next most appropriate option, as the patient needs to be aware of the risks and benefits for both procedures. It is likely that she will have been over this in her birth plan. However, it is important to cover this again before any decisions are made. E. Asking the husband to leave so you can speak to the patient in private is the least appropriate option. This removes the support of her husband and could potentially cause more distress to the patient. Also, the consultant would make a decision whether the patient was being coerced by her husband or not. You should try to maintain harmony in this scenario and removing the husband is not the way forward.

Answer 2

ANSWER: EDCBA This question requires you to consider prescribing errors and patient safety in a pressured environment. An FY1 is expected to remain calm when under pressure, demonstrate good judgement and manage uncertainty. Refer to Chapter 3 for more information on safe prescribing and prioritisation. E. Asking about Mr Brown’s fluid status is the most appropriate option. You need to find out more information from the nurse about Mr Brown before you can make an educated decision about the urgency of this task. For example, if the nurse was concerned about a low urine output, you might go and see him straight away. If there was no concern, then you would finish the prescription and see him afterwards. You should always prioritise tasks according to clinical need. D. To say you will put it on your jobs list and get to it as soon as you can is the next most appropriate option as this means you can prioritise it accordingly. Discharge summaries are important and involve prescribing and dosages. You should not be distracted from this task if possible as it may mean that the patient is discharged without the appropriate medications, or on the wrong medication etc. C. Explaining that to enable you to get the discharges done they should ask another FY1 is an abrupt response, but prioritising the discharge summaries over this routine prescription is more appropriate than (B) or (A). You should be supportive towards colleagues, but recognise when to say no. Moreover, the nurses and ward clerks are under pressure to discharge patients and they should understand your reasons. B. Going to see Mr Brown straight away is a less appropriate option. In this case, the priority of care is ensuring that the 76 Answers patient you are discharging gets the right medication and has the relevant information communicated to their GP. There is no indication in this scenario that Mr Brown is unwell and therefore his “usual” fluids can wait. A. Prescribing Mr Brown his normal saline is the least appropriate option, as this is potentially dangerous. If you overload Mr Brown with fluid you could cause pulmonary oedema. Always remember to see the patient before you prescribe in order to minimise error.

Answer 3

ANSWER: EBDCA This question is about safe prescribing and prioritising patient care. Refer to Chapter 3 for information on pressures, prescribing and prioritisation. E. Ringing the lab to see if the INR results are available is the most appropriate option, as you should find out why the results have taken so long. It may be that the sample has been missed off, in which case you would need to rebleed the patient – or ask them if they can do a repeat. Usually the lab will save part of the sample for such cases. Whilst you are not expected to stay long after your shift has ended, you have accepted responsibility for this patient and therefore you should make their care a priority before you leave. B. Handing over the request to the ward cover is the next most appropriate option, as you should make sure that the patient has a continuation of care and receives their Warfarin in a safe manner. D. Recording that the patient needs their Warfarin dosing in the notes is the next most appropriate option. Although writing in the notes does not ensure that it will get done, having a record means you can check it in the morning. Not having the patient’s Warfarin dosed could be equally as detrimental as overprescribing it. It is always good practice to write in the notes as well as make a personal list. C. Writing it onto your job list for the morning is the next most appropriate option, as you should make a note to yourself to check that this has been done. After all, this patient is now your responsibility. A. Prescribing the Warfarin anyway is not appropriate, as prescribing this without the INR result potentially puts the patient at risk of bleeding.

Answer 4

ANSWER: DACBE This question is about coping with pressure. An FY1 is expected to adapt to changing circumstances and manage uncertainty. They should also be able to re-prioritise tasks as necessary. D. Asking the nurse whether Mrs Fazi’s UO has changed since this morning is the most appropriate option as you need to find out more about Mrs Fazi before you can make a decision. A. Asking the nurse to do some basic observations whilst you order the CT is the next most appropriate option as you need to get scans approved early in the day for them to get done. The scan is, therefore, prioritised as urgent. Not completing this task may cause that patient to suffer. Your consultant will not be impressed if you don’t get the scan, as it will mess up the patient’s management plan. C. Reassuring the nurse that Mrs Fazi’s UO was fine for her size is the next most appropriate option, as it may be that the nurse hasn’t accounted for her small frame. If it was fine two hours ago, you can reassure the nurse that it is sensible to order the CT scan first before going to check on Mrs Fazi. B. Going to see Mrs Fazi immediately is not appropriate. You should not drop everything when there is no indication that there is an emergency. You should address the nurse’s concerns in a timely manner, whilst making sure that you prioritise effectively. It is better to spend 15 minutes ordering a CT scan and attend to Mrs Fazi after. E. Telling the nurse to start fluids is not appropriate, as you should not prescribe over the phone, nor should you prescribe for a patient that you haven’t been to see yourself.

Answer 5

ANSWER: ACBDE This question is about taking responsibility for your own actions and owning up to mistakes. A. Reassuring the patient that you are competent at taking blood is the most appropriate option as you should reassure the patient of your clinical skills. This response directly addresses the situation. C. Apologising to the patient for yesterday is the next most appropriate option, as you need to show the patient that you accept responsibility for causing them distress. The patient may also be more likely to consent to venepuncture on acceptance of your apology. This, however, would be best after some reassurance of your ability. B. Asking a nurse to take their blood is the next most appropriate option, as you should not lie to force the patient to consent (D) and you cannot take blood from the cannula (E) as it will Answers 77 be contaminated. Although nurses are busy, they can always help you out and some will be trained in taking blood. D. Telling the patient that you have to take their blood because there is no-one else is not appropriate. This is coercing the patient to consent. You should attempt to find someone else to take it before you tell them that they have no other options. E. Taking blood from their cannula is not appropriate. There are few occasions when you can take blood from a cannula as fluids and drugs will have passed through it. The sample would be contaminated, which means the lab would process the bloods erroneously.

Answer 6

ANSWER: BECDA This question is about professionalism. For advice on social networking refer to Chapter 2. B. Declining the friend request and explaining your reasons is the most appropriate option. The BMA (2011) recommends that you decline any offers of friendship and explain why to the patient. This most effectively addresses the problem. E. Asking your educational supervisor for advice is the next most appropriate option, as they will be able to explain what to do in this situation and turn it into a learning experience. You gain more from this than you would from ignoring the situation and not seeking advice. C. Ignoring the request is the next most appropriate option, as it is better to ignore a friend request than accept it. This would address the problem but not necessarily solve it. It would be more appropriate to learn from the experience by seeking advice. D. Asking your FY1 colleague for advice is the next most appropriate option. Although this will not directly solve the issue, your colleagues should have an understanding of professionalism and best practice and may be able to give advice. A. Accepting the request is not appropriate. It is not advisable to accept online friendships with patients or former patients. Irrespective of their discharge, they could at any point come under your care again, and it is unprofessional to enter into this kind of relationship.

Answer 7

ANSWER: BDG This question is asking whether you understand best practice following a stick injury. B. Ringing occupational health is appropriate, as they will be able to tell you immediately the protocol for stick injuries. D. Filling in a CAE form is appropriate, as when you go to occupational health, they will ask whether you have filled this in. G. Bleeping your registrar to explain the situation is appropriate, as you will have to go to occupational health, thereby leaving ITU. You should always notify a senior of a serious incident – as in this case – so they can make the appropriate arrangements such that neither your own nor the patient’s safety is compromised. A. Requesting viral serology is not appropriate, as the patient has not consented to having these investigations and it would not be in their best interests to have them done. If they were in ITU for an illness in which HIV status could benefit their treatment, then this could be considered. You, however, would not request this; it would have to be done by a senior. C. Going to A&E for anti-retrovirals is not appropriate during working hours. Occupational health will be able to give you the appropriate advice and treatment. If occupational health cannot be contacted, you should go to A&E where an appropriate risk assessment and management can be carried out. E. Asking if you can go home is not appropriate, as this would be a way of avoiding, rather than helping, this situation. F. Waiting to see if the patient wakes up to ask for their permission for serology is not appropriate. The patient is unconscious and therefore you have no idea when they will wake up. You should act quickly and promptly after a stick injury to reduce the risk to yourself as far as possible. H. Explaining to one of the nurses what has happened is not a preferred option as you should inform your senior before the nurses. The nurse’s priority is largely patient safety, whereas a senior colleague will be able to analyse the situation and manage the team to best support your needs and ensure the patient’s best interests are considered.

Answer 8

ANSWER: BFC This is about supporting a doctor in difficulty and prioritising your colleagues. B. Sitting your colleague down to talk about her problems is the most appropriate option. Your colleague is clearly distressed and therefore you should deal with this issue in a timely manner. F. Advising your colleague to talk to her educational supervisor is also appropriate, as their supervisor should be the “go-to” 78 Answers person for support. They have access to the “doctors in difficulty” programme, if needed. It is always better that you flag up issues with your supervisor rather than ignoring them and letting them be referred in via a different avenue. C. Suggesting she book an appointment to see her GP is an appropriate option. Although you don’t yet know what is causing her stress, it might be good for her to talk to someone external without the added pressure of feeling judged by her seniors. GPs are also used to seeing patients with health problems caused by stress on a daily basis and will be able to recommend a sensible way forward – including recommending sick leave. G. Seeking advice from your educational supervisor is not a preferred option. Although your educational supervisor is a good point of contact when you are unsure how to handle a situation, your supervisor can’t do much to help your colleague if she has a different educational supervisor. Your educational supervisor could be helpful if you needed to debrief on how you handled the situation. E. Suggesting she take sick leave will not address the issue and is therefore not appropriate. If it involves stress at work, taking leave will only prolong it until they return. Also her GP would be the most appropriate person to make this decision. A. Apologising and saying that you are busy is not appropriate, given how upset your colleague is, and the question clearly states that you are on a quiet ward. Moreover, this isn’t the first time she has displayed a significant amount of distress. D. Suggesting your colleague speak to her registrar is not a preferred option. While she could speak to her registrar, it is sensible to seek advice from those in the best position to help. H. Mentioning that you have to inform your consultant of her difficulties is not appropriate, as this may alienate your colleague further. As there is no indication of compromise to patient safety, you should be supportive rather than accusatory and recommend she seek help through the appropriate channels.

Answer 9

ANSWER: HEC This question is asking you about acting in the patient’s best interests for someone who does not have the capacity to refuse treatment. See Chapter 2 for more information on patient advocacy for the under eighteens. H. Discussing the situation with the nurse in charge is appropriate, as the nurses on this unit will have experience in dealing with teenagers refusing treatment. They will be able to give you advice. They also might be able to talk to the boy and get him to stay. E. Trying to persuade him to have his fingers splinted is appropriate, as you should make every effort to help this boy understand that he should have treatment. This is easier than having to force him to stay. C. Explaining that you really need to let his parents know what has happened and it would be best if he rang them is appropriate, as this boy is a minor and has been drinking alcohol, and therefore is unlikely to be Gillick competent. He is also at risk of harm from further alcohol abuse and injury. If he self-discharged and his parents knew nothing about it, your professionalism could be questioned. A. Prescribing the painkillers and letting him self-discharge is not appropriate. You should not prescribe pain relief if he has been drinking alcohol; moreover, it is in his best interests that he does not self-discharge. B. Ringing the boy’s parents without telling him is not appropriate, as this is breaking confidentiality. You should always inform the patient if you are going to do this. D. Telling him to go and see his GP if he has any problems over the weekend is not appropriate, as he has not self-discharged yet. F. Putting in a referral for social services is not appropriate at this stage as there is no need for intervention by social services on this evidence alone. G. Refusing to let him self-discharge without getting the proper treatment is not a preferred option. A teenager can only consent to treatment; they cannot refuse treatment even if they are Gillick competent, as this must be overridden if you consider treatment to be in their best interests. It is, therefore, more appropriate to get senior support. Remember to select the options that are the most appropriate to your role as an FY1.

Answer 10

ANSWER: HAD This question considers how you deal with a difficult situation involving relatives. Remember that good communication is TPP: at the right Time, with the appropriate People in the appropriate Place. H. Calling your consultant to explain what has happened is appropriate. This is a complex situation and your consultant Answers 79 really is the most appropriate person to deal with this matter. You can discuss with the consultant over the phone how you should proceed. A. Asking a nurse to take the family to a side room is appropriate, as this is a sensitive issue that would best be approached in a neutral space. Moreover, as it is a potentially volatile situation, having a colleague for support is a good idea. D. Apologising to the family is appropriate, as you will clearly have caused the relatives some distress in hearing about their mother in such frank terms. An apology demonstrates your sensitivity towards their needs. F. Asking the family if they would like to sit with their mother is not a preferred option, given the nature of the situation. They should be directed to an appropriate room to await the consultant to have a detailed conversation. They may wish to sit with their relative after this time, but it would be best to have a discussion on neutral ground rather than at the bedside. B. Asking where they heard that information is not appropriate, as it is obvious there has been error, irrespective of where they heard this information. C. Telling them you are busy and G. Finishing ordering the bloods are not appropriate, as both actions are rude and do not appropriately deal with this situation. Bloods can wait for 20 minutes whilst this issue is addressed. E. Filling in a CAE form is not a preferred option. This could be considered at a later stage after the incident has been managed appropriately. Also, the consultant may wish to complete the form in this case.

Answer 11

ANSWER: GFC This question is about acknowledging a parent’s concerns and managing them appropriately to ensure compliance with medication which is in the best interests of your patient. G. Educating the father about the advantages of using an inhaler is appropriate, as the father may have some misconceptions – in which case you can iron them out through education and help change his mind about the inhaler. F. Planning to monitor the boy’s growth on a growth chart is also appropriate, as this is addresses the concerns of the father by diligently monitoring for any side effects. By recording the boy’s growth on the chart, you are showing that you take his misgivings seriously, which will hopefully improve compliance in the long term. C. Asking the asthma specialist nurse for advice is another appropriate option, as it is likely the specialist nurse will have dealt with a similar scenario before and may have some tricks to help handle the situation. H. Asking the boy what he would like to do is not a preferred choice as although you should try to involve any child as much as possible in their care, acknowledging the parent’s disagreement should be the priority. Moreover, this boy is only nine years old and too young to consent to treatment himself. E. Getting the mother to persuade the father is not a preferred option as you must try to educate the father first, and get some more advice, before using the other parent as the mediator. The evidence of healthcare professionals should be much more effective than the mother’s opinion alone. Moreover, this would not adequately address the father’s concerns. B. Contacting social services about the disagreement is not appropriate, as there is nothing to indicate that this child is at risk of harm. D. Agreeing with the father not to use the steroid inhaler is not appropriate, as it would not be in the best interests of the child to stop his asthma medication. A. Ignoring the father’s wishes is not appropriate, as you should make every effort to resolve the dispute so that the child receives the same message from both parents. If they conflict, mixed messages can lead to increased non-compliance. Be careful not confuse the issue of consent with the issue of compliance. Although only one parent is needed to consent to treatment, in this case you want both parents on the same page so that the boy receives his medication in the appropriate manner.

Answer 12

ANSWER: AGC This is about patient prioritisation in an emergency situation and recognising your job role and limitations. An FY1 should be proactive and able to initiate assessment and investigations but know when to seek help: in this case for starting treatment. A. Continuing with your A to E assessment is appropriate, as you should always go back to basics for every patient. G. Starting the appropriate investigations but no new medications is appropriate, as you must treat the patient as new if you don’t know anything. You can hold off starting any medications until you have tried to find out whether he has any allergies or is on any medications that may interact. C. Asking a clerk to search the hospital database for any records is appropriate. Patient care should be your priority, and finding more about his medications and past medical history is essential. A clerk should have time to look through the database and print off any old clinical letters to find out more about him. 80 Answers B. Ringing your registrar is not a preferred option. You should complete your A to E assessment and then see what you can find out about his history. It says in the question that this man is stable; therefore you can assume that it is better to find out as much as you can before calling for help in this case. If the scenario was an emergency, however, you would call for help immediately. D. Searching through his mobile phone is not an appropriate option, as you should not be using friends and family to get information about a patient unless it is a last resort. You should check the hospital database first. E. Starting the treatment anyway is not a preferred option, as you should start investigations before management, G is therefore more suitable. H. Asking one of the nurses to try and track down some information is not appropriate. Nurses are busy, and you are expected to take responsibility for finding patient information – or delegate it to the ward clerk if you are busy with the patient.

Answer 13

ANSWER: CBD This is about recognising the need for senior help and tests your ability to handle patients who refuse to consent to treatment. Refer to Chapter 4 for more information on difficulties consenting patients. C. Bleeping the on-call psychiatrist is appropriate, as you have information from her boyfriend that she has been suffering from depression. Moreover, this should be treated as an attempted suicide and therefore warrants psychiatric assessment. If you spoke to your registrar, they would advise you on a psychiatric referral. In this case you would need a rapid assessment on whether she has the capacity to refuse treatment. B. Seeing if the boyfriend can persuade her to change her mind is appropriate. Using family and friends can be extremely helpful in getting patients to comply with treatment. Although this also puts him in a difficult situation, she may find it helpful talking to someone that she knows and has a close relationship with. You would still need to speak to psychiatry however. D. Calling your registrar is appropriate, as this is not something that you would be expected to handle on your own as an FY1. You should call for senior help as soon as possible as this is a challenging situation. E. Treating her under the Mental Health Act (MHA) is not a top selection, but is more appropriate than options F – Treating her under the Mental Capacity Act (MCA) – and G – Treating her under the doctrine of necessity – but you would need a full assessment before jumping to commit her to treatment without consent. You would choose E over F as she doesn’t meet the criteria for the MCA in that she understands that not having treatment will kill her. However, she is suffering from a mental health disorder and therefore can be treated against her will under the MHA. The situation of urgency is not so great that the doctrine of necessity (G) is warranted. Although this is an emergency, it is not such that you override the patient’s wishes and act in their best interests anyway. She needs further assessment of her competence to refuse treatment. A. Respecting her right to refuse treatment is not appropriate, as the history suggests that this patient’s judgement may be compromised and therefore you should explore other options first. H. Discharging her from A&E is not appropriate. You have a duty of care to this patient and dismissing her would question your professionalism.

Answer 14

ANSWER: CEH This is about patient confidentiality and protecting both the mother and the baby. This is also about recognising parental rights, and that you cannot refuse a parent access to a child just because of what the other parent says – providing, however, that you have confirmed identity. C. Asking the mother to confirm whether he is the father is one of the most appropriate options, as you should seek consent from the mother whether to allow access to her baby – particularly as the father has been out of the picture for such a long time. E. Ringing the registrar to ask for advice is appropriate, as you must consult a senior in tricky situations such as this. There could be potential problems from either the mother or this man, and you should alert seniors to this as soon as possible. H. Telling the man that he cannot see the baby until you have spoken to the mother is one of the most appropriate options, as you must explain to him that the mother also has the right to know who will be visiting her child. B. Checking the baby’s birth certificate is not one of the preferred options, as you should always confirm whether the father is who he says he is. Another way would be to get the mother to confirm that he is the father. A. Taking this man to see the baby is not appropriate, as – given the nature of their relationship – you should not allow the “alleged” father to see the baby without the mother’s permission. D. Asking the midwife for advice is not one of the preferred options as a nurse has come to you already asking for advice Answers 81 (rather than the midwife), suggesting that you are the most appropriate person to handle this situation. F. Documenting in the notes that this man wanted access to the baby is also not one of the top selections; however, you would note this down at a later stage, as well as the conversation that you had with both parents. G. Telling the man to come back another time once he has pre-arranged a visit is not one of the preferred options as fathers do not have to pre-arrange visits to see their children. Confirming his identity and getting consent is therefore more appropriate in this case.

Answer 15

ANSWER: AHF This question is about respecting a patient’s wishes and acknowledging their rights to refuse treatment on the grounds of religious principles. See Chapter 4 for more information on Jehovah’s Witnesses. A. Explaining the consequences of not having the operation is appropriate. He should fully understand the risks of refusal. Moreover, there are conservative options but they are also risky. H. Finding out why he is opposed to a blood transfusion and his preferences is also appropriate. You need to fully explore the patient’s personal beliefs before deciding on a management plan. You can then relay this information to the registrar so that they are better informed of the patient’s wishes. F. Bleeping your registrar to review the patient is appropriate, as you always need senior advice in complex situations involving patient care. They will know whether there are cell-salvage facilities at your hospital, or whether he needs to be transferred to a different hospital. They can also enter into a more complex discussion with the patient regarding the relative risks and benefits of the various options available. D. Telling him you are unsure of the options but you will find out is not a preferred option as your registrar must review the patient, in which case they can explain the options to him. G. Consulting your local guidelines is also not a preferred option. Although there should be clear guidance on this at your local trust, this can be accessed after you have all the information from the patient and passed that on to the relevant senior. You would not want to delay this patient’s treatment and therefore should act appropriately to make sure they receive senior review in a timely manner. Always be aware of where you can access such policies to read up at a later stage. B. Asking permission to contact the HLC is not a top-ranked option. You need to gain consent before you can discuss his case with an external body. The HLC will be able to give you information on the options available to him, but this will take longer than getting an internal senior review where – knowing the options – it is likely that the HLC need not be contacted. C. Advising him to contact the Watchtower society is not appropriate, as the patient does not have enough information to enquire about such a significant procedure at this stage. It is your responsibility to be an advocate for this patient and his care. E. Taking bloods and ordering pre-op investigations is not appropriate, as the patient has not consented to the operation, and therefore these investigations are not considered a necessary part of their care.

Answer 16

ANSWER: BED This question is about staying calm whilst under pressure and maintaining a good relationship with patients through effective communication. See Chapter 4 for more information on verbal communication skills. B. Asking the nurse to let the patient know he is next is the most appropriate response as it is clear he has been waiting a while and needs treatment. E. Telling the nurse to get the suture kit ready is an appropriate response as this will help you out and save some time. It is important to recognise when it is appropriate to delegate tasks. D. Apologising to him for the long wait is an appropriate response as this shows empathy. Hopefully this will diffuse his agitation and allow him to be treated. He could very well be agitated because he is in pain or he doesn’t like hospitals. It is important not to label patients as “difficult” or “drunk” as this could impair your responsibility to treat them in their best interests. A. Allowing him to self-discharge is not appropriate, as you have a duty of care to your patients. There is no indication that this patient is going to physically abuse the nurse, or that the nurse feels threatened in any way. Therefore it is best if they are persuaded to stay and receive treatment. C. Calling security is not appropriate at this stage, as he is not being threatening towards staff or others; he is merely saying that he will discharge himself against medical advice. F. Asking the nurse to tell him he should wait because you are seeing his friend is not appropriate, as it is better to let him know he is next (B). Although he may be aware that his friend is also in hospital, this could still be considered a breach of confidentiality. It is better to keep information as anonymous as possible. 82 Answers G. Leaving his friend and going to attend to his shoulder and forearm lacerations is not appropriate, as you should finish treating one patient rather than abandoning them to attend to another patient. H. Calling the SHO to review and suture him is not appropriate. You should be able to manage this situation as an FY1. You should avoid calling the SHO for minor disagreements that you are more than capable of handling. However, if this was a laceration to the forehead, you might be concerned that the increasing agitation was a manifestation of a more serious head injury, in which case you would consider bleeping the SHO for a full head injury assessment.

Answer 17

ANSWER: CAE This is about handling a situation where a patient does not wish to consent to treatment. See Chapter 3 for more information on consent in patients with capacity. C. Telling him it is important that he understands the procedure in order to consent is appropriate, as you should reiterate the need for an explanation of the procedure. The patient may still change his mind about knowing. A. Telling him you need to give him a brief explanation of the procedure is appropriate, as you must be honest with your patient and reason with him as to why he should be involved in his care. Patients should know the broad nature of the procedure, as it is possible to proceed without providing all the information on the risks and benefits. E. Asking him whether he would prefer to have a family member with him is appropriate. Even though this man has to consent to the procedure himself, many patients prefer to have a relative present. The added benefit of having a relative is that they are likely to take on board more information than the patient and can ask questions that the patient otherwise wouldn’t. This is a way of indirectly engaging the patient in a conversation about the procedure beyond the brief explanation given to him and may encourage the patient to ask questions himself. D. Phoning your registrar to consent the patient is not a preferred option. You have all the knowledge that the senior has to consent this patient. Moreover, as you will be doing the procedure yourself (under supervision), it would be more appropriate for you to gain the consent. You should try persuading the patient first, before seeking senior help. B. Asking him to sign the form without going into detail is not appropriate, as this is not getting appropriate consent – selecting this option would question your probity and integrity F. Explaining the procedure to a family member instead is not appropriate, as a family member cannot consent for a patient with capacity and can only do so in a patient who lacks capacity if they are named as a legal proxy. G. Cancelling the investigation is not appropriate, as this response is premature. You should try alternatives before jumping to cancel an investigation that is designed to help the patient – a senior would be expected to make this decision. H. Filling in the form yourself and signing in his best interests is not appropriate – this is breaking the professional code of conduct and questions your honesty and professionalism.

Answer 18

ANSWER: BDH This is about ensuring patient confidentiality in a patient who may or may not have the capacity to consent. It is also about strengthening relationships with relatives and maintaining good communication. B. Going to see how Mrs Chang is today is appropriate, as you should determine whether she has capacity or not. As she is intermittently confused, you should wait to tell her the news until she can comprehend it. Telling the family before the patient is never acceptable – unless you are sure that she is never going to have capacity. D. Telling her family about her general well-being without going into specific details is appropriate. The family will want to know how she is today and it is important that family members are kept up to date with her clinical situation. If you explain that you have to get consent from the patient they should understand and will appreciate that you have addressed their anxieties. H. Ringing the registrar to ask for advice is appropriate, as you have a duty to relay results to patients in a timely manner. You will need advice on this matter as it is likely that the family are worried and will ask you about this. Confidentiality and consent are complex issues which often extend beyond what you can see. In this respect, it is always a good idea to get a senior involved early rather than having to undo a mistake later. G. Viewing the scan yourself is not a preferred option. Although it is good practice to look at all scans as well as the radiology report, Mrs Chang and her family should take priority. Viewing normal CT scans is just as important as viewing abnormal ones and this is a learning opportunity, but, ideally, you would need a senior to talk you through the scan to consolidate information accurately. F. Letting your colleagues know Mrs Chang’s result is not a preferred option. You should let your colleagues know the results at handover or a more appropriate time. The priority here is to ascertain how you are going to get the results to Mrs Chang. Answers 83 E. Waiting until Mrs Chang asks specifically for her results is not a top selection because you should actively seek to speak to relatives when results are available – provided you have the consent from the patient to do so. A. Telling the family the good news and C Asking a nurse to tell the family the good news are not appropriate, as the patient has a right to know their results before the family, regardless of who delivers the news.

Answer 19

ANSWER: CED This is about managing interpersonal relationships and conflict within a team. You are expected to maintain harmony and work effectively as a team-player. Refer to Chapter 6 for more information on teamwork. C. Saying you cannot discuss this here and suggesting a more appropriate place is a top selection, as you never want to get into an argument on the ward in front of patients. This would be unprofessional. E. Asking Jane why she feels you are not doing your share is appropriate, as you should find out from your colleague why she has a problem with you. That way you can discuss it openly and hopefully reach a compromise. D. Suggesting that you divide the jobs evenly is appropriate, as this means that neither of you can complain about the workload. Resolving the problem between you is far more appropriate than involving seniors. You are adults and should be able to work through this. H. Reporting the bullying to your consultant and F Raising the issue with your educational supervisor are not appropriate, as you should not escalate things at this stage. Try to resolve the conflict amongst yourselves. A. Telling Jane you think she is arrogant and B Arguing that you do your fair share are not appropriate, as neither response is constructive and will likely lead to more arguments rather than a solution. G. Asking your other colleagues their opinion of you is not appropriate, as involving team members may mean asking colleagues to take sides. You are expected to maintain harmony within the team as far as possible.

Answer 20

ANSWER: BEG This question is also about teamwork and knowing how to handle a struggling colleague. B. Asking Jack whether he feels he is struggling is appropriate, as you should find out whether your colleague feels there is a problem. You can then engage in a conversation as to whether Jack has insight into his behaviour, whether he feels he is struggling, or whether he is just attempting to get out of his share of the work. E. Recommending the nurse in charge has a quiet word is as appropriate. Given that the nurses have commented on Jack’s behaviour, it would be appropriate for them to intervene. Working as part of a multi-disciplinary team, the nurse in charge should feel they have authority to speak to an FY1 if they are concerned about their behaviour. G. Informing your consultant that Jack is struggling is appropriate. Whilst it is courteous to share this information with your colleague before your consultant, the question suggests that patient care is being compromised. Hence, your consultant needs to be informed of the situation. Moreover, given a few members of the team have commented, it is right to escalate this further. If you did nothing, you would be letting down your colleagues, Jack and the patients under his care. C. Telling Jack that he is not doing his share of the workload is not as appropriate. Highlighting your awareness of the situation to your colleague may produce very little gain in terms of resolving the problem. Moreover, it may be better that this information comes from the nurse in charge who has expressed a concern. H. Telling Jack you will speak to your educational supervisor if things don’t change is not a preferred option as your educational supervisor is only in a position to give you advice and, unless they happen to be Jack’s educational supervisor too, cannot help him in the same way that his own educational supervisor should. A. Offering to take on some of Jack’s workload is not appropriate. This would increase pressure on you, in an already busy situation. Moreover, this is not addressing the real issue. You could always help them out if you have finished your jobs, but, ideally, they need to seek help from their educational supervisor if they cannot cope. D. Informing the foundation programme clinical lead is not appropriate, as there are more suitable reporting channels. F. Asking the nurses to fill in a CAE form is not appropriate, as you should speak Jack before filling in a CAE form regarding his conduct. This would also be escalated outside the team and Jack would be referred to see the foundation programme clinical lead. There is no indication in the question of one specific incident compromising care that would require filling in this form.

Answer 21

ANSWER: AEG This question is about teaching medical students to take responsibility for their own actions and own up to mistakes. A. Retaking the bloods is appropriate, as the patient comes first, and the mistake must be corrected. E. Supervising the student when taking bloods next time is appropriate, as the question indicates an issue with the samples taken. It would be helpful for you to go with the student to ensure they are doing the job correctly and to give them practical advice. You can also take this opportunity to discuss with them the difficulties associated with venepuncture. G. Suggesting the student reflects on this incident in their portfolio is appropriate. Reflecting means the student can learn about the consequences of not checking what they have done is right, and the implications for the patient. This will be an important learning point for the student which they should not ignore. C. Pointing out the mistake to the student is not a preferred option. Although you are responsible for teaching and learning, it would be better to supervise them where a problem has occurred rather than highlighting the error and moving on. F. Telling the student to bring the sample to you next time is also not a top selection, as it would be better to supervise the student rather than just checking that the bloods are OK before sending them to the laboratory. It is good practice to check them regardless – especially if it is for something like a blood transfusion. B. Reporting the student to your consultant is not appropriate, as this puts the student in an awkward position and you don’t want to scare them away from attempting venepuncture ever again. D. Ignoring their mistake is not appropriate, as the student will not learn if it is ignored. H. Telling the student to get some more clinical skills training before they go onto the wards is not appropriate, as the best practice involves real patients. They have already been trained in venepuncture and telling them to go back to square one will dent their confidence further. You should be supportive towards students to most effectively enable their learning.

Answer 22

ANSWER: ECG This question tests your knowledge of effective communication concerning patient guidance. See Chapter 2 for more information on the DVLA. E. Asking if they remember the GP advising them not to drive is appropriate, as you should reiterate that you know they have been given this information already. This is more polite than option F. C. Advising them to stop driving until their symptoms are under control is appropriate, as you should relay the advice they have already received about not driving with symptoms of angina. G. Consulting the GP for advice is appropriate. Although you should be aware of the guidance and can give patient the appropriate advice (C), this is a tricky situation and you should seek senior help on how to proceed. D. Finding out whether someone can drive them home is not a preferred option as you should find out from the GP how best to proceed with getting the patient home. This would, however, establish whether someone could come and collect them to drive them home. A. Reporting them to the DVLA is not appropriate, as you should not inform the DVLA without the patient’s consent. Also, it is the patient’s responsibility to do this, if necessary. B. Advising them to inform the DVLA is not appropriate, as it may be that the patient misinterpreted the advice given by the GP. Also, the DVLA guidance suggests that driving must cease until symptoms are under control but they need not be notified for angina. F. Reminding them that last time the GP asked them not to drive is not a preferred option as it is more aggressive than E and the patient may have forgotten they were asked not to drive. H. Asking them to hand over their keys is not appropriate, as, once their symptoms are adequately controlled, they should be allowed to drive. It would be advisable for someone to pick them up, but if you are so worried you have to confiscate their keys – they probably should be going to hospital rather than home.

Answer 23

ANSWER: BEF This question is about managing conflicts within a team and maintaining harmony whilst making sure the more appropriate action is taken. B. Asking the consultant the reasons for ordering the MRI is appropriate, as this could simply be an opportunity for learning about indications for a particular scan. Moreover, you should be putting this on the request form. E. Asking the registrar why they think the MRI is not indicated is appropriate, as this would be an opportunity for conflict resolution. If you find out the reasons that the registrar disagrees with the indication, you can explain clearly why the consultant ordered the MRI. F. Ringing the radiologist to discuss the MRI request is appropriate. Radiologists are busy, but they would appreciate you politely ringing to discuss an MRI request. Moreover, you can include any indications you discuss on the form which will help Answers 85 the radiographer select the best images. The radiologist could also raise concerns if they felt that the scan wasn’t indicated, in which case you could relay that information back to your consultant. A. Ordering the MRI as the consultant has requested is not appropriate. Although you should never undermine your consultant, you cannot ignore the comments of your registrar. Patient care should come before disagreements, and patients should only have scans when indicated. C. Ignoring the consultant and following your registrar is rarely appropriate, if ever. You should not ignore your consultant or go against their decision without their knowledge. In the event there was a change to their management plan and they could not be contacted, you would have to document everything in the notes including the arguments on both sides and why the final decision was made. Under no circumstances should you deliberately undermine your consultant. D. Telling the consultant that the registrar does not think the MRI is indicated is not appropriate, as you have a duty not to create conflict within your team. H. Documenting in the notes that the MRI was ordered but that the registrar disagreed is not a preferred option. Ideally you should not document disagreements within the team in the notes – unless they are directly relevant to patient safety.

Answer 24

ANSWER: AGB This question is about advocating for your patient and utilising expert knowledge within your team. A. Asking the specialist diabetic nurse for advice is appropriate, as they have a wealth of knowledge regarding the prescribing of insulin and, if needs be, can act as another advocate for the patient using their expertise. G. Asking the patient why they don’t want to have short-acting insulin is appropriate, as you want to find out the patient’s wishes before you can discuss them with the senior in charge. B. Calling the consultant to relay the patient’s disapproval of their regimen is also appropriate, as you must – at all times – be an advocate for your patient and meet their wishes as far as possible. If a patient is unhappy with their care, you have a duty to let your consultant know about it – tactfully! C. Prescribing long-acting insulin D Telling the patient they are on the right insulin and H Ignoring the patient’s request are not appropriate, as these options all ignore the patient’s wishes and their rights to be involved in treatment. E. Telling the patient they will have to discuss the option with the consultant is not appropriate, as this postpones the issue and it is your job to broach the subject with the consultant, not theirs. F. Writing both up on the drug chart to be delivered is not appropriate, as this leaves potential for a prescribing error if it is not clear which insulin should be delivered to the patient and when.

Answer 25

ANSWER: BCG This is about recognising the potential for a prescribing error which could potentially harm the patient. Remember not to PANIC when prescribing: Prescription, Allergy, Notes, Interactions, Clear. This error involves the prescription, i.e. ensuring that only one dose of the medication is given (where 85% of errors occur), and the notes i.e. two drug charts. See Chapter 3 for more details. B. Bleeping your registrar is appropriate, as you need to find out what happened to the other drug chart and whether the patient has received their Clopidogrel. C. Taking the chart down to A&E whilst looking for the other one is appropriate, as you can ask the nurses where this patient was and whether they know anything about the prescription as well as having a look for the drug chart. This should quickly resolve the situation and, as a matter of urgency, should be your responsibility. G. Delaying giving the Clopidogrel until the other chart is found is appropriate. Although nearly all patients receive anticoagulation in hospital for deep vein thrombosis (DVT) prophylaxis, you would not want to put them at risk of an intracranial bleed by titrating them outside of the therapeutic range. Given this patient has had an ischaemic stroke, this situation does need to be resolved promptly, but delaying is the safer option. A. Ringing the pharmacy to ask for advice is not appropriate. It is unlikely that pharmacy will be able to give you any indication of whether the patient has received the Clopidogrel or not. They can provide advice on the correct protocol – but these options are available. This question tests your knowledge of safe practice. D. Asking the patient whether they have been given the Clopidogrel is not appropriate, as the patient may not have an idea of what they have been given and you could be given false information. It is best to rely on the facts – which means finding both charts. 86 Answers E. Giving the Clopidogrel and F Giving half the dose of Clopidogrel are not appropriate, as they both put the patient at risk of bleeding. Medication should not be changed or given without having all the accurate and relevant information. H. Telling the nurses not to give Clopidogrel to the patient is not a preferred option. Although communication is key to preventing errors, the nurses would not give the prescription without seeing the chart (nor if you crossed it out). If you take the chart down with you to A&E, this will prevent the patient receiving the medication.

Answer 26

ANSWER: CEF This question is about trying to help out your colleague but recognising that it is not appropriate to pass over your bleep. C. Politely declining because you have your own patients is appropriate, as you should not take someone else’s bleep when you are not on-call. You have a responsibility for your own patients and they have to be your priority. Taking on another workload on an already busy ward is not acceptable. E. Seeing if they have any outstanding jobs you can help with is appropriate, as this is offering your colleague support so they can find some time to go and get their lunch. That way you stay on the ward without taking on any new patients. F. Offering to get their lunch for them is appropriate, as this will be helping out your colleague by saving them time so they can take a shorter break to sit down and eat it. A. Agreeing to hold their bleep is not appropriate. You should not hold someone else’s bleep – unless under exceptional circumstances such as breaking bad news. B. Offering to go with them for their lunch is not appropriate. If you want to help your colleague out, you should stay on the ward and go for your own lunch when you get an opportunity. D. Suggesting they get in touch with someone from the on-call team to hold their bleep is not appropriate. You should not give your bleep to anyone else. More importantly, if your colleague is busy, the other members of the on-call team are also likely to be busy. G. Telling them to turn it off whilst they go and get some lunch is not appropriate. There might be a sick patient whom your colleague needs to attend to, and therefore not being accessible could compromise patient care. H. Suggesting they go quickly to get their lunch is not appropriate, as this does not help out your colleague.