SJT At A Glance Practice Paper Flashcards
- An 8-year-old boy comes into A&E with a badly broken
leg. He needs surgery. You speak to his parents about the
surgery. They explain that they are Jehovah’s Witnesses and
they don’t want their son to have a blood transfusion. What
should you do?
Rank the following responses from most appropriate (=1) to
least appropriate (=5):
A. Inform your consultant about the situation
B. Consult local hospital guidelines on bloodless procedures
C. Ignore the parents’ wishes and treat the child in his best
interests
D. Tell the parents that it is unlikely that their son will need a
transfusion and they should agree to surgery
E. Tell the parents you will see what you can do
ANSWER: AEBCD
This question is about respecting and communicating a
patient’s religious views in such a way as to best accommodate
them into clinical care. For more information on
Jehovah’s Witnesses see Chapter 5. In this scenario you are
expected to seek help in a tricky situation.
A. Informing your consultant is the most appropriate option as
they have to make the final decision in this situation. If you
could only choose one of the options in this question, this
would be it. Everything else is subsidiary to recognising that
you should seek help. The consultant will also be able to advise
you on what to tell the parents (E).
E. Telling the parents you will see what you can do is the next
most appropriate option. It is best practice to value guardians’
wishes and respect that they are acting in the best interests of
the child – but you should speak to a senior before you say this.
B. Consulting the local hospital guidelines is the next most
appropriate option as this will further your own learning and
development.
C. Ignoring the parents’ wishes is not appropriate, as they
should be respected. Your consultant could override their decision
acting in the child’s best interests. However, this is an area
that would cause considerable conflict and is best avoided.
D. Telling the parents it is unlikely that their son will need a
transfusion is the least appropriate option. You cannot lie to the
parents and you do not know the likelihood of the child needing
a transfusion. You also cannot say for definite that this boy
won’t need one. If the surgery went ahead and he needed blood,
then the correct planning would not be in place and you would
be going against the parents’ (and child’s) wishes. This has
negative consequences for you as a clinician, and for the patient
and their relatives.
- You are working in a haematology clinic. You have been
seeing Mrs Alcock regularly over the past 3 months. She
says she would like to express her gratitude and hands you
a £50 cheque. What should you do?
Rank the following responses from most appropriate (=1) to
least appropriate (=5):
A. Accept the gift with thanks
B. Politely decline the gift as it is too much
C. Put the money towards a staff night out for everyone to enjoy
D. Say it is hospital policy not to accept monetary gifts
E. Record in the notes you accepted a monetary gift
ANSWER: DBECA
The GMC recommends that: “You must not encourage
patients to give, lend or bequeath money or gifts that will
directly or indirectly benefit you” (GMC 2008a).
D. Saying it is hospital policy not to accept monetary gifts is
the most appropriate option. Whether or not it is ‘officially’
hospital policy (in many trusts it is), you should decline the
patient’s gift in this manner as it shouldn’t cause too much
offence. If you simply decline the gift because it is too much
(B), then the patient might bring £20 next time. Under no circumstances
should you accept monetary gifts, as they could be
mistaken for a bribe.
B. Politely declining the gift as ‘it is too much’ is the next most
appropriate option. £50 is too much money to accept. Although
it is nice to receive gifts of gratitude from patients, you should
not be accepting large sums of money. Flowers and chocolates
as gifts are very different from money: you have to make a
sensible judgement on this.
E. Recording in the notes that you accepted a monetary gift is
the next most appropriate option. Although it is not appropriate
to accept such a generous gift, you should record it in the notes
if you did, and explain your reasons for accepting the gift.
C. Putting the money towards a staff night out is not appropriate.
Although, ideally, you should share gifts with your colleagues,
you cannot simply accept a monetary donation and
record it in another way. Usually patients will bring gifts for
the healthcare team, and so this issue is rarely a problem.
A. Accepting the gift with thanks is the least appropriate option.
This may encourage this patient to give further gifts and things
of monetary worth should not be accepted, as this could easily
be mistaken as bribery.
- You are taking blood from a 70-year-old woman on the
medical ward who was admitted following a fall. While you
are making conversation about her home circumstances, she
tells you that she recently moved in with her son after her
husband died. You enquire into how she is coping, and she
becomes tearful, telling you that her son has started drinking
and becomes very violent when intoxicated. This is the first
time she has been in hospital for injuries caused by her son.
Her son has assured her he will stop drinking so she doesn’t
want to make a fuss. What should you do?
Rank the following responses from most appropriate (=1) to
least appropriate (=5):
A. Inform the nurse in charge about the situation
B. Find out whether she has anyone else she could stay with
C. Contact your specialty trainee (registrar)
D. Give her contact details of a local domestic support group
E. Record details of your conversation in the notes
ANSWER: ACEBD
This question is asking you to consider the risk to this
elderly lady. An FY1 should always ensure the patient is the
focus of care.
A. Informing the nurse in charge about the situation is
the most appropriate option. This will directly deal with the
problem, as the nurses can refer to social services and take
the appropriate protective measures for this lady if her son tries
to visit her on the ward. Remember that nurses are the guardians
of safety and informing them about this lady is the best
thing you can do to protect her.
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C. Contacting your specialty trainee is the next most appropriate,
as a more senior member of your team can give advice on how to
appropriately manage this situation. They should be informed of
those situations where patient safety is compromised.
E. Recording details of your conversation in the notes is the
next most suitable response as you need to record the patient’s
situation accurately. It is good practice to document everything
in the notes including the situation, who you informed and
actions taken. This covers you legally, hence the saying: if it’s
not written down, it never happened!
B. Finding out whether she has anyone else she can stay with
is the next most appropriate option. Although this finds out
more about her social circumstances, it does not formally
address the problem. Also, removing her from her current
social situation would not be your decision to make. Given her
age and fragility, this would require input from social services,
OT and physios about the suitability of a move.
D. Giving her the contact details of a local support group is
not appropriate. There has not been a decision made yet as to
how the medical team will best help this lady. Giving her details
of a local domestic support group may leave her feeling dismissed
as there is much more that can be done to help her. She
should not be made to feel as if she has to resolve anything
herself at this vulnerable time.
- A 14-year-old girl attends the GUM clinic asking for an
STI check. Before you take some swabs, she tells you that
she is pregnant. You confirm this with a pregnancy test. You
ask her whether she has told anyone; she says no and that
she especially doesn’t want her parents to know. What
should you do?
Rank the following responses from most appropriate (=1) to
least appropriate (=5):
A. Tell her that you have to let her parents know because she
is under sixteen
B. Try to persuade her it would be in her best interests to tell
her parents
C. Tell her that you will respect her wishes and not tell
anyone
D. Ask your consultant to see her
E. Advise her that you are obliged to let her GP know
ANSWER: DBECA
This question is asking you to consider the health of the
unborn baby as well as the health of the teenager. Refer to
Chapter 2 for more information on under eighteens.
D. Asking your consultant to see her is the most appropriate
option, as you cannot assess Gillick competence as an FY1.
You should recognise that this is a difficult situation and you
need senior advice.
B. Trying to persuade her it would be in her best interests to
tell her parents is the next most appropriate option. Although
not every situation will warrant this action – for example, if it
was felt telling the parents could potentially harm the teenager
– you should have a sensible discussion about this. Ideally she
will be able to seek support from her parents.
E. Advising her that you are obliged to let her GP know is the
next most appropriate option, as you need to consider the health
of the unborn baby. This is where the GP steps in. Medical care
will be needed throughout the pregnancy, or for any other decisions
she may make. Informing her GP may also be a compromise,
if she refuses to let her parents know.
C. Telling her that you will respect her wishes and not tell
anyone is not appropriate. This would be dishonest, given
that you need to at least discuss it with your consultant and
the GP.
A. Telling her that you have to let her parents know because
she is under sixteen is the least appropriate response as you
should not break confidentiality without strong justification. If
she is Gillick competent, her wish for confidentiality should be
respected.
- The family of one of your patients who died is registering
a complaint about their treatment. The solicitor calls you and
asks for the medical records of the deceased to be sent to him.
What should you do?
Rank the following responses from most appropriate (=1) to
least appropriate (=5):
A. Send over the records as requested
B. Say that you will get someone senior to call them back and
take their details
C. Remind them that any requests need to be sent in writing
to the legal department
D. Call your consultant and ask them to speak to the
solicitor
E. Take the solicitor’s details and tell them you will get the
nurse to fax over the information
ANSWER: CDBEA
Remember that the duty of confidentiality persists after the
patient has died. Moreover, no party has a general right to
information, and therefore only information should be provided
that is relevant to the claim. No situation where there is a potential
breach of confidentiality should ever be rushed. Refer back
to Chapter 2 for more information on confidentiality.
C. Reminding them that any requests need to be sent in writing
to the legal department is the most appropriate option, and the
solicitor phoning should be aware of this. This directly – and
appropriately – deals with this problem. As an FY1 you should
not be involved in the sending of information to third parties,
but you can direct them to the appropriate department.
D. Calling your consultant is the next most appropriate
response, as they can more appropriately deal with this type of
request. They would also tell the solicitor to send it in writing
to the legal department.
B. Getting a senior to call them back is the next most appropriate
option. Options include contacting your F1 clinical lead,
foundation programme director or foundation programme coordinator
for legal matters. This action will delay tackling the
issue as compared with contacting your consultant.
E. Faxing over the information – even if a nurse does it – is
not appropriate. It is the legal department’s responsibility to
deal with this matter, not the medical team’s.
A. Sending over the records as requested is the least appropriate
response as this is a serious breach of confidentiality.
- You are in outpatients and you realise that your mobile
phone has been stolen. You suspect one of eight patients
could have taken it. You ring your insurance company and
they tell you that you need to call the police and get a crime
reference number. You call them, but cannot get a number
without giving the police the names of the individuals in
outpatients that day. What should you do?
Rank the following responses from most appropriate (=1) to
least appropriate (=5):
A. Give over the names of the patients so that you can make a
claim
B. Fill in a critical incident (CAE) form
C. Accuse patients you suspect and question them about it
D. Ignore it and just replace your phone
E. Report the incident to the foundation director
ANSWER: BEADC
This question requires recognition of the need to seek senior
advice in the case of a serious incident. For more information
on reporting concerns, refer back to Chapter 5.
68 Answers
B. Filling in a CAE form is the most appropriate response,
because it will put in place a system that should prevent future
thefts. Filling in the form needs to be done at the time of the
incident and not retrospectively.
E. Reporting the incident to the foundation director is the next
most appropriate option as this should help prevent future
recurrence. Your foundation director will also be able to offer
you advice on what you should do next. Remember, no matters
which involve breaking confidentiality are ever urgent.
A. Giving over the names of the patients so that you can make
a claim is the next most appropriate option. Although this does
involve disclosing patient information, it would be justifiable,
given the circumstances and having sought advice from a
senior. You are not expected to put up with having your phone
stolen
D. Ignoring the situation and replacing your phone is not
appropriate. You are not expected to put up with theft and
therefore this option – while in reality it may seem less complicated
– is not what you should do.
C. Accusing patients you suspect and questioning them about
it is the least appropriate response. This could produce potential
distrust between you and your patients creating a potentially
difficult situation for yourself.
- A 16-year-old girl comes into A&E with diabetic ketoacidosis
(DKA). She is admitted and treated. The following
morning you are arranging her discharge. You discuss her
diabetic control with her. She says that she can’t be bothered
with the insulin as it’s too much hassle. What should
you do?
Rank the following responses from most appropriate (=1) to
least appropriate (=5):
A. Educate her about the importance of compliance
B. Arrange for the specialist diabetic nurse to see her before
she goes
C. Make a note of her non-compliance on the discharge
summary to the GP
D. Ask her parents to speak to her about compliance if they
come to collect her
E. Ask her why the insulin is such a problem
ANSWER: BEACD
This question is asking you to consider your opportunities
for learning. An FY1 should be willing to learn from others
and from their experiences.
B. Arranging for the diabetic specialist nurse to see her is the
most appropriate option, as they will have a wealth of experience
with non-compliance and may have some tricks up their
sleeve to deal with the situation. Ideally, you should utilise their
skills and expertise by sitting in on their consultation so the
nurse can educate you at the same time. This is the type of
experience you may choose to reflect on in your eportfolio
afterwards.
E. Asking her why the insulin is such a problem is the next
most appropriate option. Is it because she can’t do the same
things as her friends? Or maybe she has a problem with her
insulin regimen? Information means you can seek advice for a
more suitable treatment plan.
A. Educating her on the importance of compliance is the next
most appropriate, as it is your duty to inform patients of their
responsibility for their own health. You should use every available
opportunity you can for health promotion. The specialist
diabetic nurse, of course, would do this for you as part of their
consultation.
C. Making a note of her non-compliance on the discharge
summary to the GP is the next most appropriate option. The GP
should be made aware of the issue so that it can be followed up.
D. Asking her parents to speak to her about compliance is the
least appropriate option as – given her age – you should try to
engage with the patient first, rather than relying on her parents.
You should still speak to her parents though, as they may also
need educating about compliance. It would be best practice to let
the girl know that you would like to speak to her parents about
this. If there were circumstances in which she disagreed, you
should seek senior advice from your consultant or registrar.
- A 32-year-old woman presents to A&E for a head laceration.
She claims that her boyfriend hit her, and she fell and
hit her head. You smell alcohol on her breath. On questioning
you find that she has left her two children at home under
the supervision of her boyfriend who has also been drinking.
You are worried about the children, what should
you do?
Rank the following responses from most appropriate (=1) to
least appropriate (=5):
A. Call social services to report your concern
B. Call your registrar to assess the mother and discuss the case
C. Fill in a referral form for social services
D. Tell the mother it is protocol that you put in a referral to
social services
E. Tell the mother that you are concerned about the children,
given her injuries
ANSWER: BEDAC
This question incorporates social services protocol and
expects you to demonstrate awareness of boundaries of
your own competence. An FY1 should readily seek help
when required. Refer back to Chapter 2 for specific information
regarding social services.
B. Calling your registrar to discuss the case is the most appropriate
option, as you will need senior consultation for advice
regarding social services. They will also be able to guide you
as to how to discuss the matter with the mother.
E. Telling the mother you are concerned about the children,
given her injuries is the next most appropriate option as you
first need to explain the reasoning behind your concerns
D. Telling the mother that it is protocol that you put in a referral
to social services is the next most appropriate option as you
need to explain what you are going to do about your concerns.
You should always try to inform the parent that you are putting
in a referral to social services, unless you feel that the child will
be put at risk if you do so. In either case you would bring in a
senior.
A. Calling social services is the next most appropriate option,
as they will be able to advise on the phone whether an urgent
response is necessary – i.e. to call the police to the house – or
whether a referral through the usual mechanism is necessary.
Social Services are the experts in this situation; hence, they
should be the ones dictating the action plan.
C. Filling in a referral form for social services is the least
appropriate option. Any form should be filled in at the time of
concern when all the relevant information can be collected;
but in this complex case it should be done by a senior. Moreover,
as there is an immediate concern, the phone call should
be made before the form is completed. However, if this was a
more “routine” case, then the phone call would not be necesAnswers
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sary and you would simply consult with a senior about completing
the form.
- Mrs Smith is 53-year-old lady who suffered with heart
failure for many years. She has expressed a wish to receive
no further treatment and go home to rest in peace. The
nurse comes to see you the following day, saying that her
husband has arrived and is angry that you are sending her
home to die. He feels his wife is “out of her mind and not
thinking straight”. What should you do?
Rank the following responses from most appropriate (=1) to
least appropriate (=5):
A. Go and see Mrs Smith to find out whether she remains firm
in her wishes
B. Ask the nurse to inform the husband it is Mrs Smith’s
decision
C. Explore the husband’s concerns
D. Refer to psychiatry
E. Persuade Mrs Smith to go with you to speak to her husband
about her wishes
ANSWER: CAEBD
This question is about responding to a difficult situation
between a patient and their relatives and respecting the wishes
of both parties. An FY1 should understand both the relatives’
and the patient’s views for effective communication. See
Chapter 4 for more advice on effective communication.
C. Exploring the husband’s concerns is the most appropriate
thing to do. This is because it is important as far as possible to
respect the feelings of those close to the patient and meet their
needs for support.
A. Going to see Mrs Smith is the next appropriate option, as
you must find out whether her wish to refuse treatment is still
the same. Moreover, you must gain consent to discuss Mrs
Smith’s wishes with her husband.
E. Persuading Mrs Smith to go with you to speak to her
husband about her wishes follows on from A, as there is an
opportunity for conflict resolution if both parties communicate
their wishes to one another. This should be done once you have
obtained consent.
B. Asking the nurse to inform the husband it is Mrs Smith’s
decision is not really appropriate. While it is possible for team
members to resolve this issue, ideally it should be the person
with the best rapport. Nurses have a great deal of communication
with patients and their relatives and it is likely they’ve
approached you because they feel out of their depth. You should
appreciate the delicacy of this matter; simply directing the
nurse without exploring the issue further is not appropriate.
D. Referring Mrs Smith to psychiatry is the least appropriate
option as there is no indication that Mrs Smith needs psychiatric
assessment, nor of it being any benefit to her.
- Your FY1 colleague Mark has turned up late again for
handover, and you smell alcohol on his breath. You know
he has been having some family problems recently. You
suspect the alcohol is from last night, but you cannot be
sure. What should you do?
Rank the following responses from most appropriate (=1) to
least appropriate (=5):
A. Report Mark immediately to the foundation programme
director
B. Ask your educational supervisor for advice
C. Suggest to Mark that he explain the situation to the specialty
trainee (registrar)
D. Report the situation immediately to your consultant
E. Have a quiet word with Mark after the handover to ask how
he is coping
ANSWER: CDEBA
This question is about recognising and reporting dangerous
practice. An FY1 should challenge unacceptable behaviour
that threatens patient safety. Refer back to Chapter 5 for
more information on reporting concerns.
C. Suggesting to Mark that he explain the situation to the
registrar is the most appropriate option. This reduces the immediate
risk to patient safety as the registrar can suggest the
appropriate actions to take. This is an urgent situation as there
is a potential compromise for patient care. However, you might
not want to go straight to the consultant (D), as issues like this
will affect your colleague’s reputation. It is best if Mark can be
persuaded to report his irresponsible behaviour.
D. Reporting the situation immediately to your consultant is the
next most appropriate option. You have a responsibility to your
patients, and your duty of care to them overrides your loyalty to
your colleague. Serious incidents should immediately be raised,
if they compromise patient safety. You are not in a position to
deal with them yourself, so seniors must get involved.
E. Having a quiet word with Mark after the handover is the
next most appropriate option, as you should offer your colleague
the chance of an explanation and find out more about
the situation. It is important that you support your colleagues,
but having this conversation would not directly influence the
outcome of the scenario as you should address the issue of
patient safety first and foremost.
B. Asking your education supervisor for advice is the next
most appropriate option. Getting confidential advice on clinical
dilemmas should be considered, but this action will not address
the immediate problem. You should consult those in your
immediate team before more external clinicians. Although your
educational supervisor will be at your hospital, it may take time
to contact them.
A. Reporting Mark immediately to the foundation programme
director is not appropriate. Reporting procedure is well outlined,
and it is not your place to report this directly to the
foundation programme director. They would expect you to
go through the appropriate channels and try locally first. Moreover,
the foundation director may not be on site and may take
considerable time to respond which may result in a compromise
in patient care. Your foundation programme director would
eventually hear about it via the Doctors in Difficulty referral
pathway.
- An elderly woman is brought in by ambulance to A&E.
She doesn’t speak English. The paramedics say that she was
found collapsed on the street and a passer-by called 999.
She is stable, but you suspect she needs to be kept in overnight.
You name some languages and she nods at “Urdu”.
It is 7.30 p.m., what should you do?
Rank the following responses from most appropriate (=1) to
least appropriate (=5):
A. Arrange for an interpreter to come to the hospital
B. Use an online translation service
C. See if the patient can contact a friend or relative to
interpret
D. Arrange for a telephone interpretation
E. Find a colleague on the ward and see if they can translate
ANSWER: EDABC
This question includes a common problem with translation
services and tests whether you can demonstrate initiative.
Refer back to Chapter 4 for more information on working
with interpreters.
E. Finding a colleague on the ward to see if they can translate
is the most appropriate option. Whilst it is not an ideal solution,
70 Answers
doctors and nurses remain impartial translators, and this means
that you can get any urgent information from the patient while
arranging for a more formal translator. Moreover, Urdu is a
common language, and the likelihood of finding someone in
the hospital who speaks it is high. Telephone services (e.g.
language line) are expensive and should be considered as the
next option if your colleagues cannot help.
D. Arranging for a telephone interpretation is the next appropriate
option, as most A&E departments should have access to
this service as arranged by the foundation trust. This service
allows access to interpreters anytime, day or night and offers
impartiality and confidentiality.
A. Arranging for an interpreter to come to the hospital is the
next most appropriate option. No matter where you are working,
the likelihood of getting an interpreter at 7.30 p.m. is slim. You
could, however, leave a message and arrange this for the following
morning. Typically, bilingual services are only available
from 9 a.m.–5 p.m.
B. Using an online translation service would require a computer
nearby that allows access to this service. It also requires that
you type in the information, which is time-consuming. Moreover,
there are limited languages available, and there is no guarantee
that the translation is accurate. These services are generally
inadequate for anything beyond the most basic of needs.
C. Seeing if the patient can contact a friend or relative to interpret
is not appropriate. The use of an ad hoc interpreter is discouraged,
and even more so if they have a close relationship with the patient.
This option should be avoided where at all possible.
- You are working on an oncology ward. It is a Saturday
night and a patient is asking you for the results of his
myeloma screen. The nurse tells you that the patient is
going to complain if they do not get the results soon. The
patient is anxious and cannot understand why it is taking
so long. You do not have their results yet. What should you
do?
Rank the following responses from most appropriate (=1) to
least appropriate (=5):
A. Explain to the patient it is unlikely you will get the results
before Monday
B. Tell the nurse to go and explain to the patient that it is not
possible to get the results until Monday
C. Call the laboratory and put an urgent on the results
D. Call the registrar and ask them to speak to the patient
E. Apologise to the patient for the delay but explain that it is
a weekend and unfortunately you will not have the results until
Monday
ANSWER: EDACB
This question assesses your honesty and integrity with
regard to the patient relationship and ensures that you
make the patient your first concern.
E. Apologising to the patient for the delay is the most appropriate
response – and also the most honest. By apologising you are
showing empathy and acknowledging the patient’s distress.
D. Calling the registrar to speak to the patient is the next most
appropriate response, as this is a delicate issue that should be
dealt with by a senior colleague.
A. Explaining to the patient they are unlikely to get the results
before Monday is the next most appropriate response. This is
an honest answer, but does not acknowledge the patient’s concerns.
It would be more appropriate to have a senior review the
situation than to provide an inadequate explanation – especially
when there has been the threat of a complaint.
C. Calling the laboratory to put an urgent on the results is the
next most appropriate option, but this is unlikely to make any
immediate difference to the situation as it is the weekend and
other more urgent results will take priority.
B. Telling the nurse to explain the delay to the patient is not
appropriate. It is important that you go and see the patient
yourself and explain the situation. It is likely that the patient is
threatening to make a complaint because they are worried.
Hence, they will appreciate you taking the time to see them,
helping to ease their anxiety.
- You are working on a respiratory ward. A locum consultant
prescribes antibiotics for Mr Jones for communityacquired
pneumonia. You know these particular antibiotics
are outside hospital guidelines. What should you do?
Rank the following responses from most appropriate (=1) to
least appropriate (=5):
A. Prescribe the treatment as the consultant wishes but document
in the notes they are outside of hospital guidelines
B. Show the guidelines to the consultant and ask whether the
antibiotics should still be prescribed
C. Ask the consultant the reasons for prescribing those
antibiotics
D. Follow the guidelines and ignore the consultant’s prescription
E. Ring pharmacy and find out their recommendations
ANSWER: BCEAD
This question analyses your consideration for hospital
policy and your ability to negotiate it with colleagues in an
appropriate manner.
B. Showing the guidelines to the consultant to ask whether
they should be prescribed is the most appropriate option as this
addresses the issue and considers the options for prescribing.
C. Asking the consultant the reasons for prescribing those
antibiotics is the next most appropriate option, because it may
be that the consultant is aware of the guidelines but has prescribed
them for a particular reason. Alternatively, these may
be the ones that he typically uses, in which case you could enter
into a discussion about local guidelines.
E. Ringing pharmacy to find out their recommendations is
more appropriate than A or D. Pharmacy are an excellent source
of guidance on the appropriate prescribing of medications. You
should consult expert advice rather than either brush aside your
concerns or undermine a colleague.
A. Prescribing the treatment the consultant wishes outside
guidelines without good reason is not appropriate, as you
should not ignore a situation where you think something is
wrong. However, it is more appropriate to follow your consultant’s
wishes than to undermine their expertise and not carry out
their management plan (D).
D. Following the guidelines and ignoring the consultant’s prescription
is the least appropriate option, as this means going
against the advice of the consultant. If the patient were to deteriorate
after you ignored their advice, you would be held soley
responsible.
- You are working a night shift on a surgical ward. A
patient already on treatment for sepsis starts to rapidly
deteriorate. It is nearly midnight. You complete your A
to E primary survey and the patient is stable for the
moment, but you feel you are out of your depth. You
call the surgical registrar, but they tell you to call the
medical team because they are busy in theatre. When you
bleep the on-call medical registrar, they tell you it is not
their responsibility and to find someone else. What should
you do?
Rank the following responses from most appropriate (=1) to
least appropriate (=5):
A. Call the surgical consultant at home
B. Start basic management for the patient
C. Call the surgical registrar again, explain the situation and
ask for advice
D. Ask a nurse to arrange for someone to help you
E. Put out a periarrest call on 2222
ANSWER: CBDAE
Patient safety is always a first priority. It is important that
you recognise your limitations and seek appropriate support
when necessary. This should ideally be someone more experienced
than yourself.
C. Calling the surgical registrar again is the most appropriate
option, as they should give you the appropriate advice regarding
immediate management steps that can be taken.
B. Starting basic management for the patient is the next most
appropriate option, as you should take initial steps such as ordering
investigations, taking bloods, prescribing fluids etc. as part
of your secondary survey. These steps are within your remit, and
you should optimise the care you can give in this situation.
D. Asking a nurse to arrange for someone to help you is the
next most appropriate option as this involves sharing responsibility
for the patient. The nurses are perfectly equipped to seek
help for you while you attend to the patient. Moreover, they
will have knowledge of who else could be contacted in this
situation – for example, the hospital may have a critical care
outreach team. However, this is less appropriate than informing
seniors, as it does not directly address patient care. Moreover,
you have more knowledge of the patient’s clinical condition
and it is better to relay this information yourself.
A. Although calling the consultant at home is not a nice thing
to have to do, it is perfectly acceptable and would be the next
appropriate action if no seniors were available on site. They
will, however, be 20, 30 minutes away from the hospital
. . . maybe more. The patient, at the end of the day, comes
first and as the consultant’s responsibility overall, he/she would
rather be contacted regarding problems with patient care.
E. Putting out a periarrest call on 2222 is not appropriate, as
the question clearly says that the patient is stable. This should
only be used if you feel the patient is going to arrest. Think of
calling 2222 like dialling 999: for instance you would think twice
about calling if someone in a restaurant looked very well and
was simply having heartburn rather than having a heart attack.
- A patient with end-stage motor neurone disease asks
you to give them the lethal injection. You explain to
them that this is not legal in this country. What should
you do?
Rank the following responses from most appropriate (=1) to
least appropriate (=5):
A. Explore the patient’s reasons for wanting the lethal injection
B. Tell the patient’s partner how they feel
C. Ask the patient to talk to their partner about their feelings
D. Refer the patient to psychiatry
E. Explain to the patient about an advance directive and start
the process
ANSWER: AECDB
This question explores patient focus. An FY1 is expected
to appreciate needs, build relationships with patients, be
respectful of patients’ wishes and work in partnership about
their care. However, FY1s are not expected to follow
patient’s wishes when it involves euthanasia!
A. Exploring the patient’s reasons for wanting the lethal injection
is the most appropriate option, because it is important that
you find out from the patient whether it is due to depression or
whether they are trying to convey specific preferences about
their treatment.
E. Explaining to the patient about an advance directive is the
next most appropriate option, as you would highlight the
choices available to them concerning their treatment.
C. Asking the patient to talk to their partner about their feelings
may result in them getting additional advice and support
if they so wish. This response, however, would not address the
immediate issue.
D. Referring the patient to psychiatry is not appropriate, as it
is not clear that the patient has a mental health issue. You would
also need senior input before making this decision.
B. Telling the patient’s partner how they feel is the least appropriate
option as you would be breaking patient confidentiality.
- An 83-year-old man is brought in to A&E after a fall.
He has severe dementia and is obviously in pain, but is
unable to tell you where the pain is coming from. After
examination you suspect he has a broken hip. This is confirmed
by X-ray. A decision needs to be made about treatment.
However, he lacks capacity. His wife is deceased and
his daughter, detailed as his next of kin, lives in Australia.
What should you do?
Rank the following responses from most appropriate (=1) to
least appropriate (=5):
A. Contact your local Independent Mental Capacity Advocate
(IMCA) organisation
B. Try to contact his daughter in Australia
C. Speak to the registrar about scheduling him onto the surgical
list
D. Check through the notes for any legal documentation
E. Start treatment anyway and give him analgesia
ANSWER: ECADB
This question tests your knowledge of consent where a
patient does not have capacity in an emergency situation.
Refer to Chapter 5 for more information.
E. Starting treatment is the most appropriate option, as the
patient comes first, and you do not need consent to give analgesia
– this is a basic treatment option that provides overall
benefit for a patient in pain.
C. Speaking to the registrar about scheduling him onto the
surgical list is the next most appropriate option. The responsibility
for decisions about treatment in an emergency situation lies
with the treating doctors. Emergency treatment must be provided
straight away. A senior needs to be made aware of the situation
ASAP as a broken hip can be potentially life-threatening.
Although it would not be your responsibility to schedule a patient
onto the surgical list, this option directly advocates for treatment
of the patient by directly involving their care.
A. Contacting your local IMCA is the next most appropriate
option. Typically, an IMCA is appointed in non-emergency
situations where a family member or friend cannot be contacted.
This service advocates for patients who lack capacity to
ensure that their feelings and wishes are considered. As broken
hips are scheduled onto the trauma list, this is an emergency
situation; however, as the patient has severe dementia, they will
be useful for assistance in less pressing matters. It is, therefore,
appropriate to contact them early in case a difficult decision has
to be made post-surgery.
D. Checking through the notes for any legal documentation is
the next most appropriate thing to do, as this will give you an
idea of the patient’s wishes as well as any documents detailing
72 Answers
a legal proxy whom you could contact to make his decisions
for him. Although this will be useful in informing decisions, a
thorough search should not prevent emergency treatment and
this could take some time given his age and co-morbidities.
B. Trying to contact his daughter in Australia is the least
appropriate option. Whilst you should contact a patient’s relatives
and close friends when trying to make a decision about
“overall benefit”, they do not have the final say in treatment.
You can assume that the patient would want them involved if
they lack capacity, but again this is different when the situation
is an emergency. This would not change your management of
the patient and is therefore the last action you would take in
this situation.
- It is a quiet afternoon on your surgical ward. The
consultant asks you to come and assist with a private list
in the afternoon at a different hospital. What should
you do?
Rank the following responses from most appropriate (=1) to
least appropriate (=5):
A. Ask your educational supervisor for advice
B. Agree to help your consultant
C. Decline and go down to the theatres to see if you can assist
with any surgical cases
D. Decline because you have responsibilities on the ward
E. Ask your fellow FY1 colleague for advice
ANSWER: CDAEB
This question is about juggling your work commitments
with opportunities for career progression.
C. Declining and going to assist in theatres is the most appropriate
option, as you should utilise quiet times on the ward to
seek out additional learning opportunities. This option is appropriate
and enhances your educational development. Whilst it is
not appropriate to leave the hospital, it is perfectly acceptable
to seek experiences on site and, as a trainee, you should be
taking advantage of such situations.
D. Declining because you have responsibilities on the ward is
the next most appropriate option, as this immediately addresses
the issue. Whilst this would be a good opportunity, you should
not leave the hospital during paid working time. It would not be
fair to your colleagues to increase their workload. Nor would it
be fair to your patients whose care may suffer as a result. If you
explained this to the consultant, they should understand this.
A. Asking your education supervisor is the next most appropriate
option as you should ask for senior advice when faced with
a dilemma. Moreover, educational supervisors should be in
your hospital; therefore, you should receive a timely response
from them.
E. Should you not be able to contact your educational supervisor,
seeking advice from a fellow FY1 is the next most appropriate
response. Although they won’t have the same level of
expertise, they may have faced a similar situation, or know
someone else who has.
B. Agreeing to help your consultant with the private list is the
least appropriate option as it is unacceptable to leave without
formally handing over patients. Moreover, it is not appropriate
to leave your patients while you are being paid by the NHS to
care for them – no matter how quiet the ward is!
- You are seeing a patient in minors in A&E on a Friday
night. A nurse comes in to tell you that a patient is being
verbally aggressive and threatening because they haven’t
been seen yet and thinks people are “jumping the queue”.
The nurse suspects the patient has been drinking alcohol.
What should you do?
Rank the following responses from most appropriate (=1) to
least appropriate (=5):
A. Go and see the patient and tell them they will not be treated
unless they calm down
B. Ask the nurse to call security
C. Tell the nurse to get someone else to see the patient because
you are too busy
D. Explain to the patient that you are very busy but that you
will see them as soon as possible
E. Physically restrain the patient
ANSWER: BDACE
Nurses handle a great deal on the wards. If they come to
see you about an aggressive patient, they will likely have
tried everything to calm them down, so be sympathetic.
B. Asking the nurse to call security is the most appropriate
option. Staff are not expected to tolerate abuse and calling
security is a necessary precaution as there is a potential for
this situation to get worse. Security can act quickly if it does
escalate.
D. Explaining to the patient you are busy but will see them as
soon as possible is the next most appropriate option, as patients
will often calm down if given a rational explanation.
A. Going to see the patient and telling them they will not be
treated unless they calm down is more appropriate than C and
E. However, a patient’s right to treatment should never be
influenced by their behaviour, and the GMC recommends that
you do not use treatment as a bargaining power.
C. Telling the nurse to get someone else to see the patient is
not appropriate. You might be the only person that the nurse
could find to help. If you did nothing and something were to
happen to the nurse because there was no one else around, then
you would be held accountable. This would be an error in
judgement. You should prioritise this situation as more urgent
than the patient you are seeing to in minors, as there is a potential
for harm.
E. Physically restraining the patient is the least appropriate
option. You cannot physically restrain a patient without just
cause, as restraint may be considered physical assault. This
would be the role of security.
- A 60-year-old Indian man comes into A&E with a
history of fits. He was discharged 2 days ago from ITU. His
wife is with him, but she does not speak English. He is very
confused, disorientated and, from your A to E assessment,
clearly unwell. You cannot get a history. It is 4 p.m. on a
Monday afternoon. What should you do?
Rank the following responses from most appropriate (=1) to
least appropriate (=5):
A. Proceed anyway with routine examination and investigations
B. Ring the GP to get background information on the
patient
C. Ring the patient’s family to obtain the information
D. Ask ITU to fax over their notes from the previous
admission
E. Arrange for an interpreter before you proceed
ANSWER: ADBEC
This question is about prioritisation and problem-solving. An
FY1 should demonstrate initiative when it comes to information
gathering and think creatively to solve problems.
A. Proceeding anyway with routine examination and investigations
is the most appropriate option as you must rule out
anything potentially life-threatening before you get more information
on this patient’s history. You can obtain a lot of information
from examination alone. It is not acceptable to neglect
examining a patient just because you can’t get a good history.
Patient care is your clinical priority and should always be done
Answers 73
first. If needs be, he can be treated as a new patient rather than
as a failed discharge.
D. Asking ITU to fax over the notes from the previous admission
is the next most appropriate option, as this will give you
access to the notes quickly – if they have them. They also might
have information on the patient’s family, translators, etc.
B. Ringing the GP to get background information is the next
most appropriate option. The GP should be the first port of call
for patient information. In this case, however, the GP may not
have the most recent information on the patient, given that it is
only two days since discharge and it typically takes longer for
discharge information to be received. Don’t be alarmed if the GP
asks to call you back on your bleep, or to fax the notes over – this
should be standard protocol to protect patient confidentiality.
E. Arranging for an interpreter is the next most appropriate
option. However, interpreters take time to arrange and it is
unlikely that you will get one within an hour. This situation is
potentially urgent and therefore other options should be
explored in preference to this.
C. Ringing the patient’s family is the least appropriate option.
This would break confidentiality and there is no guarantee that
they speak English either. His wife is already present with
whom the interpreter could consult.
- You are working as an FY1 on an obstetrics and gynaecology
ward. A 29-year-old woman is admitted four hours
into labour. This is her first pregnancy. She is requesting a
Caesarean section (CS), but there is no medical indication
for it at this stage. This is different from her birth plan, but
the patient is demanding that she be given the care that she
wants. What should you do?
Rank these responses from most appropriate to (=1) to least
appropriate (=5):
A. Ask a midwife on the ward for advice
B. Ring the consultant obstetrician to make them aware of the
situation
C. Explore the patient’s reasons for wanting a CS
D. Explain the overall risks and benefits of both a CS and
vaginal birth
E. Refuse the CS as it is not medically indicated
ANSWER: CBDAE
This question is about working in partnership with patients
about their care whilst bearing in mind their best interests.
In terms of a patient’s best interests concerning a CS, indications
for a CS include (NICE 2011):
• Presumed foetal compromise
• ‘Failure to progress’ in labour
• Breech presentation (∼10% of all CS)
• Placenta praevia
• Multiple pregnancy
When a woman requests a CS NICE (2011) recommends:
• Discussing the overall risks and benefits of a CS and vaginal
birth, taking into account circumstances, concerns and priorities
• Including a discussion with other members of the obstetric team
(obstetrician, midwife and anaesthetist) to explore reasons for a
request and to ensure the woman has the accurate information
• Offering perinatal mental health support for women with
anxiety about childbirth
• If this is unsuccessful, offering a planned CS with a willing
obstetrician. If the consultant obstetrician is not willing, the
team should refer to one who is.
C. Exploring the patient’s reasons for wanting a CS is the most
appropriate option. This demonstrates consideration for their
needs and is the first step towards reaching a solution.
B. Ringing the consultant obstetrician is the next most appropriate
option as they will be making the final decision and need
to be made aware of the situation as soon as it arises. You will
also be able to discuss with them over the phone the risks and
benefits of both a CS and vaginal birth (D), which you could
relay to the patient before the consultant arrives.
D. Explaining the overall risks and benefits of a CS and vaginal
birth is the next most appropriate option. NICE (2011) recommends
this is carried out before any decision is made regarding
a CS. If the patient still wants to change her birth plan at
this point, then you have already appropriately informed your
seniors.
A. Asking the midwife on the ward for advice is the next most
appropriate option. The midwife is part of the obstetric team
and will undoubtedly have dealt with this situation before.
However, they would not make a final decision for this patient,
and therefore you should approach an obstetrician in preference
in this case.
E. Refusing the CS is the least appropriate option. This patient
has a right to a CS regardless of whether it is medically indicated,
and you are not in a position to refuse such treatment to
this patient.
