Case study for NURS2000 practice exam

You are a registered nurse/registered paramedic who works in a small town in regional
Australia. This small town is frequently without a resident medical practitioner, but it does
have a small, well-equipped hospital and a dedicated team of nurses and paramedics.
Fortunately, the local council is progressively minded and focused on the health of the local
population. As a result, all nurses and paramedics are heavily involved in primary care and
community outreach in addition to their regular roles. The local council encourages close
and ongoing professional therapeutic relationships between nurses and paramedics, and
the local population.

Your patient, Ruby, is a 37-year-old woman who was born and raised in China. She has now
been living in Australia for the past 17 years and she is an Australian citizen. She has lived in
this small town for the past two years as her husband wanted to move out of the ‘rat race’
of the busy city. Ruby is married to an older man (in his late forties), and she has two young
male children – one six-year-old and one now 18-month-old. Ruby is a registered nurse and
has been one since she moved to Australia from China to complete her nursing studies as an
international student. She works five days per week in a large town approximately 70
kilometres away (one-way) in a senior training role at the large hospital there. Ruby has
never worked in your small town, but she is known to several of your colleagues who speak
highly of her knowledge and work ethic.

You are visiting Ruby on a Saturday morning as part of your community outreach role. Part
of this role is to check on her 18-month-old son who was born in the local hospital. When
you arrive, both children look well and happy and the six-year-old is happily playing with
Lego on the carpeted living room floor. Their dog, Snow, who looks old and overweight to
you, lies asleep on the couch pressed up against Ruby’s leg during your visit. You conduct a
brief assessment on Ruby and find the following:

 Blood pressure: 140/90

 Heart rate: 85 beats per minute and regular
 Temperature: 36.70C
 Respiratory rate: 16 breaths per minute
 Oxygen saturation: 99% on room air
 Weight: 98kg
 Body mass index (BMI): 33.2

You haven’t personally met Ruby before, so you spend some time talking with her. You
comment on her lovely and large home and Ruby states that her and her husband are quite
wealthy. It turns out that her husband still works in the city during the week and only
returns to home on the weekend. Even then, some weekends he remains in the city
including this weekend when you visit. Ruby describes this as “stressful” and “not ideal” as
she has been left to care for the two children mostly by herself. She admits that she has
limited friends in this new town, and she must heavily rely on the local council’s “excellent
but expensive” childcare services. Ruby states that her parents have just arrived from China
in the last week for an extended stay and she was hoping that they could “takeover” most of
the childcare duties. However, her father smokes continually in the house (“I tell him to

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stop, and my mum does nothing to stop him!”) and her mother gave Ruby’s youngest son a
glass cup to drink from two days ago which he broke and then cut the palm of his right hand
deeply. When you ask Ruby where her parents are this morning, she says that they have
walked to the local supermarket to buy groceries. “It’s nice to have a break from them,”
before she adds, “and they’ve only been in Australia five minutes!”

You ask Ruby some questions about her health. She denies any history of diabetes but
states she apparently snores and says, “I drive my husband crazy, but he loves me!”. She
wakes up with a sore throat and a headache most days. She then mentions that she had
gestational diabetes during her recent pregnancy and shrugs her shoulders stating, “you’re a
health professional, you know what it’s like with cakes and sweets and stuff lying around
your workplace!” Ruby tells you that she has seen dietitians in the past; however, it wasn't
the right time as she was busy with her career and her first child. She again shrugs her
shoulders and exclaims, “I have a master’s degree in health professional education, for
goodness’ sake! I know all the stuff I should be doing!” Ruby does not have a regular
General Practitioner (family doctor) but instead relies on advice and prescriptions when
necessary from one of her medical colleagues at work. That doctor checked her blood
pressure recently and stated, “it’s a bit high” and “you probably should do something about
that”. You ask Ruby if she has any concerns about her cardiovascular health and she says
“no” before she volunteers “my dad has high blood pressure, and my mum has type 2
diabetes”. “And my dad’s probably got lung cancer with all his smoking!” she says as she
laughs to herself. Ruby denies any mental health concerns but mentions that she
experienced postnatal depression following the birth of her most recent child (“that wasn’t
pretty!”) and that, now, “the drive to and from work and the kids are killing me!” She
describes her mood as “okay” and she notes how rewarding she finds her job and her work
colleagues (“but it’s go, go, go when I’m there!”). Ruby has never smoked, she does not use
non-prescribed drugs (legal or illegal) and she admits to drinking “close to a bottle” of wine
most evenings after the children have been put to bed. She states apologetically, “yeah,
yeah, I know, it’s a tiny bit too much! I only admitted it because you’re a health
professional! You know what the stress is like! I probably should cut down. My husband and
I drink a bit when he is here, and my dad loves Australian red wine!”

You ask Ruby about her hobbies and social supports. “Ha!” she exclaims loudly. “My wine,
Netflix and gorgeous Snow here,” she says as she rubs the dog’s belly. Indeed, you have
noticed that Ruby has been gently stroking the dog throughout your entire conversation as
he lies nestled alongside her. “He’s worn out now, but Snow is my oldest friend in
Australia,” she adds quietly. Ruby volunteers that she used to be a keen middle distance
runner (“can’t do that anymore with kids!”) and that she really enjoys messaging her two
friends, Matt and Michelle, many times a day because “they make me laugh”.
Unfortunately, both Matt and Michelle live back in the city and Ruby has not seen them in
over a year. Ruby says that “the old lady who lives next door seems kind enough” but
otherwise Ruby claims that she knows almost no one in town.

Ruby is prescribed the following medication:

 drospirenone and ethinylestradiol (‘Yaz’) – 1 tablet PO QD (indicated as an oral
contraceptive)
 diazepam – 2.5 to 5mg PO PRN (indicated for anxiety)

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  temazepam – 10mg PO QD nocte PRN (indicated for insomnia)

nocte = at night
PO = by mouth (“per os”)
PRN = as needed (“pro re nata”)
QD = daily (“quaque die”)

Questions

Please write your answers in the answer booklet provided

and NOT on this question sheet.

Questions Marks
1. Describe five (5) psychosocial factors about Ruby from the case study. 10 marks

1. Social Isolation – Ruby has few friends in her new town and limited social
support.
2. Work-Life Stress – Long daily commute and balancing a demanding job
with parenting causes chronic stress.
3. Parental Conflict – Cultural and behavioral differences with her parents
(e.g., smoking, childcare habits) add strain.
4. Alcohol Use – Ruby consumes nearly a bottle of wine most nights,
indicating problematic coping mechanisms.
5. Past Mental Health Issues – Ruby had postnatal depression and currently
reports low mood and stress.

2. Describe five (5) things that are unknown about Ruby from the case study and 10 marks
that you will need to assess further.

1. Mental Health Status – Extent and severity of her current psychological

wellbeing.
2. Extent of Alcohol Dependence – Whether Ruby meets the criteria for
alcohol use disorder.
3. Dietary and Physical Activity Habits – Details of her current nutrition and
exercise routines.
4. Sleep Quality and Sleep Apnoea – Whether she has undergone a sleep
study or received a diagnosis.
5. Parenting and Support Strategies – How effectively she manages
parenting without support.

3. Describe one (1) nurse-led/paramedic-led intervention to address Ruby’s alcohol 5 marks

use disorder. Explain why you have selected this intervention.

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 Brief Intervention using Motivational Interviewing (MI)
This client-centered approach helps explore Ruby’s ambivalence and
increase her motivation to reduce alcohol intake. It is appropriate given
Ruby's insight and health knowledge but lack of sustained behavior
change.

4. Discuss how you would monitor and evaluate the nurse-led/paramedic-led 5 marks
intervention you have identified in question 3.

 Short-term: Use AUDIT-C screening tool at follow-up visits.

 Medium-term: Monitor Ruby’s self-reported alcohol consumption
through a diary.
 Long-term: Evaluate physical and mental health changes, including mood,
liver function tests, and blood pressure.

5. The first part of the Health Belief Model relates to the person’s Background. List 10 marks
the two (2) sections within Background and identify the information already
known about Ruby from the case study.

- Sociodemographic Factors – 37-year-old Chinese-Australian, lives in

rural town, mother of two, works full-time as a senior nurse educator.
- Knowledge/Experiences – Highly educated in health, previous gestational
diabetes, postnatal depression, and knowledge of family health risks.

6. The second part of the Health Belief Model relates to the person’s Perceptions 10 marks
about their self-efficacy. This second part is divided into threat and expectation
both of which are then further sub-divided. List the two (2) sections within both
threat and expectation and discuss Ruby’s perceptions about her overall health.
Finally, describe what appears to be Ruby’s perception about her overall
perceived self-efficacy.

Threat:

 Perceived Susceptibility: Aware of family history of hypertension and

diabetes.
 Perceived Severity: Downplays seriousness of her current alcohol use and
high blood pressure.

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 Expectation:

 Perceived Benefits: Knows what she should be doing but lacks consistent
action.
 Perceived Barriers: Time, stress, social isolation, and family conflict inhibit
action.

Perceived Self-Efficacy: Moderate — she has health knowledge but struggles

with applying it due to psychosocial pressures.

7. The third part of the Health Belief Model relates to Action. List the two (2) 5 marks
sections within Action and identify the information already known about Ruby
from the case study.

- Cues to Action – Visit by healthcare professional, previous doctor’s

advice, family history.
- Health Motivation – States desire to reduce alcohol and improve life
balance, but hasn’t yet acted on it meaningfully.

8. Discuss what stage of the transtheoretical model of behaviour change Ruby 5 marks
appears to be at regarding her overall health. Explain what would need to
change for Ruby to be in a different stage.

Stage: Contemplation – She acknowledges alcohol use is “a bit too much” but
hasn’t taken action.
To move to Preparation or Action, she needs structured support and goal-
setting, such as referrals or self-monitoring plans.

9. Identify the intervention used to assess Ruby’s willingness to make a change in 10 marks
her behaviour (1 mark). List the core components and techniques of this
intervention (9 marks).

Intervention: Motivational Interviewing (MI)

Core Components & Techniques:

1. Open-ended questions
2. Affirmations
3. Reflective listening
4. Summarizing
5. Eliciting change talk
6. Rolling with resistance

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 7. Developing discrepancy
8. Enhancing self-efficacy
9. Supporting autonomy

10. Describe five (5) protective factors Ruby has access to. 10 marks

1. Education – Master’s degree in health education.

2. Financial Stability – Describes her family as wealthy.
3. Employment – Rewarding and stable job.
4. Family Support (Potential) – Parents are visiting and may help with
childcare.
5. Pet Companionship – Emotional support from her dog Snow.

11. Describe one (1) defence mechanism that may be employed by Ruby to cope. 2 marks

Humour – Ruby uses sarcasm and laughter to downplay serious issues (e.g.,
alcohol use, parenting stress), which may mask distress.

12. 3 marks
Discuss whether you believe Ruby to have an internal or external locus of
control.

External Locus of Control – Ruby attributes her poor lifestyle to external factors
like work stress, parenting load, and family interference rather than internal
control.

13. 5 marks
Describe five (5) stakeholders in the case study.
- Ruby – Primary client and mother.
- Her Children – Dependents affected by her wellbeing.
- Her Husband – Often absent but impacts household dynamics.
- Her Parents – Could provide or hinder support.
- Healthcare Providers – Nurses, paramedics, and doctors offering care
and education.

14. Discuss how as a registered nurse your input could promote a transdisciplinary 5 marks
approach to Ruby’s care. How would this differ from a multidisciplinary
approach?

- As a nurse, I can bridge gaps between services (e.g., dietetics, mental

health) through coordinated education, assessments, and community
referrals.

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 Transdisciplinary = Integrated roles with shared goals.
Multidisciplinary = Parallel roles working independently within their
own scope.

15. Discuss whether you believe Ruby is suffering from burnout from her work. What 5 marks
are the signs and symptoms of burnout?

Yes. Signs include:

 Emotional exhaustion (“the drive and the kids are killing me”)
 Low motivation and reliance on alcohol
 Social withdrawal
 Irritability and frustration with her parents
 Poor sleep and stress-related physical symptoms (headaches, sore throat)