Reading Jahshan OET Collection

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For
Medicine, nursing, dietetics, dentistry, occupational therapy, optometry, pharmacy, physiotherapy,

podiatry, radiography, speech pathology and veterinary science
Kaplan
Sample
Practice
E2Language
OET Online
IRS
No. Test Question Answer Your Score
Page Page
1 Kaplan Strategies 3 53 / 42
& Practice Set
2 Kaplan Practice Test 57 81 / 42
3 Sample Test 1 83 102 / 42
4 Sample Test 2 104 125 / 42
26 Sample Test 3 (NEW) 553 572 / 42
5 Practice Test 1 127 147 / 42
10 E2language Test I 229 249 / 42
11 E2language Test II 251 267 / 42
12 E2language Test III 269 284 / 42
13 E2language Test IV 286 307 / 42
14 E2language Test V 309 329 / 42
15 OET Online Test 1 331 346 / 42
16 OET Online Test 2 348 365 / 42
17 OET Online Test 3 367 383 / 42
18 OET Online Test 4 385 403 / 42
19 OET Online Test 5 405 422 / 42
20 OET Online Test 6 424 440 / 42
21 IRS Test 1 442 463 / 42
22 IRS Test 2 465 485 / 42
23 IRS Test 3 487 507 / 42
24 IRS Test 4 509 529 / 42
25 IRS Test 5 531 551 / 42
1
Kaplan Strategies & Practice Set
Page 3
Reading Part A
Hypertension: Texts
TEXT
TEXT A
A
The medications used to treat high blood pressure fall under one of the
following categories describing their mechanism of action:
ACE-inhibitor
Angiotensin-II antagonist
Calcium-channel blocker
Thiazide-type diuretic
Which medication a patient receives depends on their age and ethnicity.

Black patients of African or Caribbean descent are known to have higher
risk of hypertension. Whenever a patient’s treatment regime fails to
work, it is stepped-up by adding an additional medication of a different
category.
Page 4
Text
TEXT B
B
Controlling High Blood Pressure
Advise patients to stop smoking; offer advice for help and counselling.
Patients can use nicotine aids and join local ‘stop smoking’ schemes. If unable
to quit smoking, encourage them to reduce daily cigarette consumption.
Patients must not drink alcohol to excess and stick to weekly alcohol limits,
which are 14 Units per week MAXIMUM for both males and females.
Encourage regular exercise, at least 150 minutes of moderate aerobic activity
(such as walking, cycling, swimming) per week, including strength exercises
on at least two days per week.
Recommend a balanced and healthy diet, low in saturated fats and sugars.
Patients should opt for lean proteins, brown carbs, and fruit and vegetables.
Advise those with high blood pressure to purchase a blood pressure monitor
to use at home so that they can measure blood pressure regularly.
Patients should keep a blood pressure log and take to each check-up
appointment.
Provide strategies to help minimise stress and anxiety at home and at work.
Offer advice about help and counselling, recommend local services for stress,
anxiety, or depression.
Page 5
TEXT C
The following are indicators of high blood pressure:
Severe, sudden and recurring headaches

Frequent nose-bleeds
Visual changes, such as blurred vision
Dizziness
Shortness of breath
Chest pain
Numbness
High blood pressure is one of the biggest risk factors for heart disease
and stroke. It is a worldwide issue and is becoming increasingly
common. There would be a significant reduction in the incidence of heart
disease and stroke in the UK if all patients with high blood pressure
made lifestyle changes and took steps to lower and control it.
__________________________________________________________
Page 6
TEXT D
The table below shows the systolic and diastolic values for normal and abnormal
blood pressure.
Category: Systolic Pressure Diastolic Pressure
(mmHg): (mmHg):
Hypotension 70–89 or 40–59
Normal Blood Pressure 90–119 and 60–79
Prehypertension 120–139 or 80–89
Stage 1 (Mild) Hypertension 140–159 or 90–99
Stage 2 (Moderate) - 160–179 or 100–109

Hypertension
Stage 3 (Severe) Hypertension 180–209 or 110–119
1. For each of the four texts, A – D, briefly summarise the information given.
A-
B-
C-
D-
2. Look in Text A to find who has an increased risk of high blood pressure.
3. Look in Text D to find which category of blood pressure a diastolic

measure of 85 mmHG would belong to?
4. Look in Text B to find what type of exercise patients should do two

times each week?
5. Look in Text C to find what would happen if patients with high blood
pressure made an effort to lower it.
Page 7
Thyroid: Texts
Text A Text A
TEXT A
Diagnosis of Hypothyroidism in Patients Taking L-thyroxine
Patients frequently take thyroid hormone with an inadequate diagnosis of
hypothyroidism, this is clinically relevant and should be addressed to optimise
treatment. Presenting complaints include fatigue, weight gain, and oligo
menorrhea. If the patient and doctor establish that the diagnosis was not
complete – the best approach is to stop treatment for 5 weeks. L-thyroxine and
desiccated thyroid extract are the most common treatment options. After
stopping treatment, serum T4 and TSH concentrations will indicate euthyroidism
or a primary hypothyroid state.
Carry out tests 10-14 days after stopping drug therapy and analyse the results for
physiological hypothyroidism from suppression of the pituitary-thyroid axis by
the exogenous hormone.
Alternative approach: halve the L-thyroxine dose and assess thyroid function
after 5 weeks.
Patients taking an excessive amount of L-thyroxine may experience the

following symptoms:
mood changes/swings
arrhythmia
tremor
chest pain
bone pain
diarrhoea
Advise patients to be aware of these symptoms, and to seek immediate medical

help if more than one of these symptoms occurs.
Page 8
Text TB Text B
‫ل‬
Minimally invasive video-assisted thyroidectomy
Procedure:
Usually undertaken with the patient under general anaesthesia.
Small incision made above the sternal notch
Endoscope inserted through incision
Dissection of thyroid lobe undertaken
Operative space maintained using external retraction
Do not use gas insufflation
Care must be taken to identify and preserve recurrent laryngeal

nerve
Safety:
Postoperative morbidity rates, meta-analysis of 9 studies:
10% (29 out of 289) for minimally invasive video-assisted
thyroidectomy
14% (42 out of 292) for conventional, open thyroidectomy
Superficial laryngeal nerve injury reported in 2% (5 out of 300) of

patients
Can lead to:
Weakened voice (hoarseness)
Loss of voice (aphonia)
Problems with the respiratory tract
Training:
Minimally invasive video-assisted thyroidectomy requires skills
additional to those of conventional, open thyroid surgery.
Adequate training is important for surgeons using the minimally
invasive procedure
The procedure is only suitable for a minority of patients with
thyroid disease
Those requiring surgery
Those with thyroid glands of an appropriate size
Page 9
Text C
BRAF V600E Mutation Testing for Thyroid Cancer
Mutation testing should be undertaken to avoid unnecessary surgery and reduce

the number of surgical procedures for patients with suspected thyroid cancer.
Fine needle aspiration is the most common method to obtain thyroid tissue
samples
Cytological examination cannot distinguish between benign and malignant
neoplasms
If the biopsy is positive – the affected lobe is surgically removed
The sample undergoes a pathological microscopic examination
If the testing indicates cancer – the remainder of the thyroid gland is
removed
A test for a BRAF V600E mutation can be performed using a commercially

available testing kit
The BRAF V600E mutation has more than 99% specificity for thyroid
cancer
A positive result means that there is more than 99% chance the cancer is
malignant
This makes it possible to remove the thyroid in one operation rather than
two
Page 10
Th
Text D
TEXT D
Thyroid Function Test Results and Analysis

Thyroid Function Test Results and Analysis
T TSH
FT4 FT3 FT 4 FT 3 Clinical Clinical
Decreased Normal Normal — thyroxine treatment/ingestion

— subclinical hyperthyroidism
— drugs: steroid, dopamine
— non-thyroidal illness
Decreased or Decreased or — or
Decreased non-thyroidal illness
Normal Normal Normal — early phase post-treatment for -
hyperthyroidism
— pituitary disease
— congenital TSH deficiency
Increased Normal Normal — subclinical hypothyroidism

— heterophile antibody (interferes with
TSH assay)
— erratic compliance with thyroxine
therapy
— malabsorption of thyroxine in previously
stable patient
— drugs: amiodarone, cholestyramine, iron
— recovery phase of non-thyroidal illness
— TSH resistance
Normal or Normal or Normal or

— drugs: heparin, amiodarone
Increased Increased Increased
— anti-iodothyronine antibodies, anti-TSH -
antibodies
— familial dysalbuminaemic -
hypothyroxinaemia (FDH)
— thyroxine replacement therapy
(including non-compliance)
— non-thyroidal illness, acute
psychological disorders
— TSH-secreting pituitary tumour
Page 11 resistance to thyroid hormone

In which text can you find information about . . .
6. identifying the risk of malignant cancer of the thyroid? __________

7. which patients are suitable for a thyroidectomy? __________
8. the symptoms of patients receiving insufficient treatment? __________
9. changing the dosage of thyroid medication?
__________
10. assessing the thyroid function in those taking L-thyroxine? __________
11. Posssible complication involved in thyroid removal procedure ? __________
Answer questions 12 – 16 using the 4 texts on pages 71 to 74. For each

answer, use a word or short phrase from the text. Each answer may
include words, numbers or both. You should complete these questions
in 5 minutes.
12. What will the level of FT4 be in patients undergoing thyroxine

replacement therapy?
13. What should patients who are taking L-thyroxine do if they notice
arrhythmia and mood swings?
14. Which type of thyroidectomy has an increased chance of morbidity?
15. Test results for a patient with subclinical hyperthyroidism will show
what level of FT3?
16. What can be tested for using a commercially available kit?

Page 12
Answer questions 17 – 21 using a word or short phrase from the 4 texts
on pages 71 to 74. Each answer may include words, numbers or both.
You should complete these questions in 5 minutes.
17. If thyroid function tests indicate that TSH has (17)

, this could suggest heterophile antibodies.
18. Following a thyroidectomy, if the patient experiences aphonia, this

suggests injury to the (18) .
19. If tests reveal that the BRAF V600E mutation is present, it is extremely
likely that the patient has (19) .
20. During a thyroidectomy, the endoscope is inserted into a cut made in the
(20) .
21. To optimise hypothyroidism treatment, (21) can

be used to detect euthyroidism, once the current treatment is stopped.
Page 13
Reading Part A: Practice Set
TIME: 15 minutes
Look at the four texts, A – D, on pages 78 – 81.

For each question, 1 – 20, look through the texts, A – D, to find the
relevant information.
Write your answers in the spaces provided in this Question Paper.
Answer all the questions within the 15-minute time limit.
Anaemia: Questions
Questions 1 – 6
For each question below, decide which text (A, B, C or D) the

information comes from.
You may use any letter more than once.
Page 14
Anaemia: Texts
TEXT A
Anaemia is defined as an overall decrease in red blood cell mass. There

are many varying causes of anaemia, which all present with some
general symptoms. Anaemia results in a lack of red blood cells in the
blood. Because it is the haemoglobin in red blood cells that carries
oxygen from the lungs to the rest of the body, a decrease in red blood
cells results in less oxygen going into the tissues. This causes a state
known as hypoxia, or reduced oxygen in body tissues.
The common symptoms of all anaemias are those of hypoxia:
Weakness, fatigue, difficult or laboured breathing

Pale skin
Headache and light-headedness
Chest pain (if the patient already has a disease of the arteries
supplying the heart)
Page 15
T Text B
TEXT B
There are many classification systems to differentiate anaemias. The most

commonly used is based on the size of the red blood cell. Anaemias with red
blood cells that are smaller than normal are known as microcytic anaemias. If the
anaemia has normally sized red blood cells, it is referred to as a normocytic
anaemia. Finally, if the red blood cells are too big, it is known as a macrocytic
anaemia. Normocytic anaemias are further broken up into whether or not there is
an increased number of young red blood cells (a.k.a. reticulocytes), which is an
indication if the bone marrow is working properly—for example, if the red blood
cells are being destroyed (haemolysis), there should be higher reticulocytes
because there is no effect on the bone marrow’s ability to produce new cells.
Page 16
TEXT C
While there are many different causes of anaemia, laboratory studies and unique
features of the patient can be used to help differentiate between various
aetiologies.
Laboratory studies used to diagnose anaemia include:

Haemoglobin (Hb)—a measure of the protein that transports oxygen in the
red blood cell
Haematocrit (Hct)—a measure of the percentage of red blood cells in the
blood
Red blood cell amount (erythrocyte count)—a measure of the number of red
blood cells in the blood
A general diagnosis of anaemia can be determined by the following values:
Haemoglobin level
Males: less than 13.5 g/dL
Females: less than 12.5 g/dL (women have a generally lower haemoglobin
because of blood loss during the monthly menstrual cycle)
Haematocrit
Males: less than 45% red blood cells
Females: less than 37% red blood cells (women have a generally lower
haematocrit because of blood loss during the monthly menstrual cycle)
Red blood cell amount

Male: less than 4.7 million cells/mL
Female: less than 4.2 million cells/mL (women have a generally lower red
blood cell amount because of blood loss during the monthly menstrual
cycle)
While these laboratory tests are good estimates of the red blood cell mass, they
are not perfect. Red blood cell mass is very difficult to measure, and therefore
these laboratory tests are used together to assess whether or not someone has
anaemia. Page 17
TEXT D
The treatment of anaemia depends heavily on the type of anaemia that

the patient is experiencing. However, there are several overarching goals
of treatment.
If possible, treat the underlying cause of the red blood cell loss.
For example, if the patient has anaemia because of blood loss,
give a blood transfusion.
Identify and treat any complications that have occurred because of

the anaemia.
Educate the patient on how to manage their anaemia.
For example, a patient with anaemia because of iron deficiency
can supplement their treatment with iron rich foods, such as leafy
green vegetables.
Alternatively, a patient with anaemia caused by vitamin
deficiency should be advised to increase their intake of folic acid
and B-12. Note that patients who follow vegetarian or vegan diets
may struggle to meet B-12 requirements, so eating fortified foods
and using supplements should be advised.
Page 18
__________
1. treating patients with anaemia?
2. the symptoms of hypoxia? __________
3. methods used to identify anaemic patients? __________
4. the different types of anaemia? __________
5. the levels of haemoglobin in a woman with anaemia? __________
6. how red blood cell size affects anaemia? __________
7. What should vegan patients with vitamin deficiency anaemia be

encouraged to add to their diets?
8. If there is a decreased number of young red blood cells, what type of

anaemia is being dealt with?
9. How will a patient’s breathing sound when experiencing a significant

reduction of oxygen in the body’s tissues?
10. A male with anaemia must have less than what percentage of red blood
cells?
11. What is an increase in the number of reticulocytes an indication of?
12. What reduces the amount of red blood cells in some patients?
13. What should be treated in anaemic patients, after identifying the cause?
14. How are the different types of anaemia most commonly distinguished?
Page 19
Questions 15 – 20
Complete the sentences below by using a word or short phrase from
the text. Each answer may include words, numbers or both.
15. Anaemia caused by (15) should be treated with a blood

transfusion.
16. Patients suffering from hypoxia and chest pain are likely to also have a
(16) .
17. If (17) is functioning properly, high reticulocyte anaemia is

likely to be present.
18. A number of tests may be necessary to diagnose anaemia, due to the

difficulties involved in measuring (18) .
19. Patients with anaemia caused by (19) should be instructed to

adjust their diet.
20. When identifying the type of aetiology, (20) of the patient

should be considered, in addition to laboratory studies.
Page 20
Reading Part B
Take 4 minutes and 30 seconds to answer questions 1 – 3 below.
Continuity and coordination of care

1. All healthcare professionals must be involved in the safe transfer
of patients between each other and social care providers. This
includes:
Sharing all relevant information with colleagues that are
involved with your patient’s care, both inside and outside the
team, including when the care handover is done at the end of
duty, and when care is delegated or referred to other health or
social care providers.
When possible, check that a named team or clinician has
appropriately taken over responsibility when your role has
ended in providing a patient’s care. This is most important in
vulnerable patients who do not have capacity.
When care is transferred or delegated to another healthcare
professional, it is your responsibility to ensure that the person
providing care has the appropriate skills, qualifications and
experience to provide adequately safe care for the patient.
The policy document tells us that a healthcare professional’s
(A) duty to care for a patient continues after a referral.

(B) ability to look after a patient should be decided by superiors.
(C) obligation to check up on transfers does not apply to all
patients.
Page 21
2. Assessing Physical Restraints
We first advise providers to verbally de-escalate and offer

medications as a method of calming an agitated patient down.
However, if these do not work and the patient becomes violent, a
standard protocol for physical restraints should be followed.
Trained personnel should carry out the actual action of
physically restraining the patient and a bed with restraints should
be prepared ahead of time. Medications should be drawn up in
IM form and be ready to be given once the patient has been
physically restrained. A physician should then assess the patient,
first debriefing staff on the situation that caused the patient to be
placed in restraints and then speak to the patient personally to
determine their understanding of the same events.
Cardiopulmonary status and restraint tightness must be assessed
and the patient’s level of pain and distress documented.
The guidelines inform us that physical restraints
(A) can only be administered to patients by qualified staff.

(B) must be applied before patients become aggressive.
(C) should only be used on patients as a last resort.
Page 22
3. Calling a Consult
No physician can handle every patient by themselves. No matter

the specialty, there will come a time where you need to reach out
for additional help. If you’re working at an outpatient office,
you’ll look to a specialist in a different institution. If you’re
working inside the hospital, you’ll call a particular service with a
consult. Different institutions have different protocols on how to
call the consult, but at the very core, you will need to present the
patient to the physician you’ve consulted. You should start by
introducing yourself and your role on the treatment team. Give a
short summary of the patient, their medical history, why they’re
in the hospital and what’s happened so far. You should then go
into the reason you’re consulting the specialist and what you’re
looking for – whether it’s treatment recommendations, a
procedure, or to arrange a service transfer. Conclude by asking if
they have any other questions that you can help answer.
The guidelines advise physicians on
(A) seeking advice from others.

(B) receiving authorisation for care.
(C) referring patients to different departments.
Page 23
Take 6 minutes to answer questions 4 – 7 below.
4. Ensuring Patient Privacy
Patient privacy is legally governed by HIPAA, which establishes

strict standards for healthcare providers when sharing patient
information. Every hospital will have guidelines healthcare
employees must follow to avoid committing an HIPAA violation,
which can result in termination from employment and/or severe
fines. Employees must avoid talking about identifiable patient
information with other people that are not involved in their care.
This also includes discussing patient details in a public setting
like a hallway or elevator. When sending information about
patients to other providers, it is important to use secure forms of
transmission such as hospital email and fax. Avoid easy but
unprotected methods like texting or personal email. Dispose of
any identifiable information in specially marked bins for later
incineration.
What point does the training manual make about confidential

documents?
(A) They must not be consulted in an open area.

(B) They must only be shared via work email.
(C) They must be destroyed after use.
Page 24
5. Extract from guidelines: Post-Exposure Prophylaxis for HIV
When working with patients with suspected or confirmed HIV

infection or other bloodborne viral illnesses, medical staff must
remember that they are at risk of inoculation injury, and take
necessary precautions to prevent infection.
It is important that strict guidelines are adhered to and rapid

action taken post-exposure, in order to reduce potential risk of
infection post-incident, control spread, and prevent future
incidents. Exposures are defined as percutaneous inoculation via
a needlestick injury, or a splash of potentially infected body
fluids/blood into mucous membranes (such as eyes or mouth) or
an open wound. Immediate action should be taken to wash the
injury or exposed region with copious amounts of water; any
wounds should be encouraged to bleed, and prevented from
beginning to clot before the area has been cleaned. Senior
members of staff should be informed immediately, and the
Occupational Health department contacted. All cases will be
dealt with confidentially and all blood samples taken from the
affected member of staff will be labelled anonymously. An
Incident Form should be completed urgently. Occupational
Health will rapidly arrange contact with, and testing of, the
source patient.
What should staff with open cuts exposed to a bloodborne viral illness
do?
(A) avoid contact with other staff.
(B) prevent a scab from forming.
(C) disinfect and cover the wound.
Page 25
6. Codeine and Ultra-Rapid Metabolisers
Codeine is a widely used opioid analgesic used to treat mild to

moderate pain. The ability to metabolise codeine to morphine
can vary considerably between individuals. Codeine has a very
low affinity for opioid receptors and its analgesic effect is due to
its conversion to morphine. The hepatic CYP2D6 enzyme that
metabolises a quarter of all prescribed drugs, including codeine,
regulates this process.
Individuals who have two or more functional copies of the

CYP2D6 gene are ultra-rapid metabolisers - able to metabolise
codeine to morphine more rapidly and completely. Even at
normal doses, individuals who are ultra-rapid metabolisers may
have life-threatening or fatal respiratory depression, or
experience signs of overdose. Individuals with no active copies
of CYP2D6 (“poor metabolisers”) show reduced morphine
levels. In this scenario, alternative pain management strategies
must be established.
Healthcare professionals and prescribers are encouraged to

educate patients about possible side effects associated with
codeine use.
The guidelines inform us that codeine can cause side effects in patients
(A) who suffer from opioid addiction.

(B) who take it together with morphine.
(C) who have a particular genetic makeup.
Page 26
7. Guidelines: Incisional Hernia
In 12–15% of abdominal operations, incisional hernias occur

post-operatively. An incisional hernia passes through an incision
previously made during surgery, when the closure of abdominal
tissues fails to heal properly. Be sure to cover during check-ups:
incisional hernias are the second most common type of hernia.
Check for hernia
— Look for abnormal protrusion of tissue or organ through the

cavity in which it is situated.
— Remember that hernias are most common in the abdomen,
but can also appear in the upper thighs and groin region.
Remember that the major risk with incisional hernias is

strangulation: the organ in the hernia devascularises and the
tissue degenerates. This must be identified at the earliest
opportunity – delay can lead to septicaemia and shock.
Treatment is mostly surgical: a mesh can be used to strengthen

the area. Otherwise, open and keyhole repairs remain an option,
however, better outcomes have been reported with the use of
mesh repairs.
The guidelines inform us that incisional hernias
(A) are caused by surgery.

(B) form when patients cut themselves.
(C) occur more frequently than other hernias.
Page 27
8. Procedural Guidelines for Set-up and Administration of

Intravenous Fluids
Intravenous (IV) fluids are infused directly into the veins of

patients via a cannula in cases of severe dehydration, electrolyte
imbalance, blood loss, and in surgery. Intravenous lines can also
be used for administration of drugs directly into the blood of a
patient, resulting in faster action. The guidelines below illustrate
the correct procedure for setting up and administering IV
therapy.
Firstly, always check that the fluid bag is not damaged and that
the liquid inside it is clear. Secondly, there have been reports of
incomplete patient notes, so it is crucial that you check for
details such as fluid type and expiration date and record these in
the patient notes immediately. Thirdly, it is vital that all clinical
staff introduce themselves with their full name and role to all
patients they engage with; only after confirming patient details
and obtaining their consent should one begin the IV set-up.
Finally, be extra diligent when calculating the drip rate as to
avoid any errors. Feel comfortable to approach a fellow
colleague for assistance if uncertain at any stage.
The main purpose of the guidelines is to advise staff on

(A) the procedure to follow when fitting an IV.
(B) how to check for issues with IV infusions.
(C) what to do before administering an IV.
Page 28
9. For the attention of all paediatricians:
As a paediatrician, one must always remember that the patients

are not the doctor’s only concern; we must also factor in the
anxious parents worried about their child. This can be an
additional challenge for staff in a department that is already busy
and stressful, but a duty which must not be neglected. Parents
who seek paediatric care for minor conditions are not
intentionally impinging on medical care for those patients who
more urgently need it. Therefore, time should be spent speaking
to these parents and offering reassurance and support as
appropriate, rather than ignoring them or making them a last
priority. Ten to fifteen minutes spent in conversation with these
families will save much more time in the long-run and prevent
countless bleeps and calls from them, which could otherwise
have been avoided. In addition, it is vital to be aware of
alternative potential causes for the parental anxiety that could be
rooted in past events and experiences, or caused by problems in
their personal life.
The purpose of the email is to advise paediatricians to be
(A) mindful that parents may not always agree with the proposed
treatment.
(B) aware that even minor illnesses can be distressing for parents.
(C) understanding and patient when explaining conditions to
children.
Page 29
10. To all front-line medical staff,
Recently, we have been noticing a steady increase in no-

show appointments at the practice. Previously, we did not have a
concrete policy on cancellation deadlines or missed appointment
fees. Given that no-show appointments not only take up valuable
time from our providers, but also prevent another patient from
utilising these time slots, it is in our best interest to discourage
patients from missing their appointment. Going forward, office
staff will call every patient at least 48 hours before their
appointment to remind them of the date and time of their
appointment. If the patient cancels within 24 hours of their
appointment time, office staff will make a note in the patient’s
chart. If the patient has more than three such cancellations, he or
she will then be issued with a $25 fee to reschedule the
appointment. Patients who are using medical insurance are
exempt from this fee and instead should have their chart
forwarded to a provider for further evaluation. We understand
that this new policy may result in some difficulties for staff, so
we will allow fees to be waived in extreme circumstances. We
will also set the start date of this policy six months from today’s
date, so all patients will have sufficient time to be informed of
the new rules. Please make sure that all patients are aware of
these changes at the end of each appointment.
What is the email from the admin team asking front-line staff to do over
the next 6 months?
(A) Charge a fee to patients who cancel their appointments three

times.
(B) Call patients with a reminder 24 hours prior to their
appointment.
(C) Inform patients of the changes to be implemented.
Page 30
Reading Part B Practice Set
1. Preparation of Injection
Lidocaine is a local anesthetic that is often injected

subcutaneously before minor medical procedures such as
laceration repair, excisional biopsy, and hormone implantation. A
key step to prepare for this procedure is clearing a suitable
workspace and obtaining any necessary supplies. First, be sure to
check with your provider about the concentration and mixture of
Lidocaine to be used. Epinephrine is often included to constrict
local blood vessels for longer duration, but can increase the risk
of causing ischemia in areas with poor blood supply (fingers,
ears, toes). Sodium bicarbonate can also be added to avoid pain
during injection due to Lidocaine’s acidic pH. Be sure to obtain
the proper sized needle and syringe, which will be dependent on
the location of the injection and the size of the area requiring
anesthesia, respectively.
Why is epinephrine added to Lidocaine injections?
(A) to numb the area

(B) to prolong the effects
(C) to reduce patient discomfort
Page 31
2. Policy Reminder: Collecting Collateral Information
Collateral information is an important factor in determining

appropriate disposition for psychiatric patients in the Emergency
Department. Often, patients with psychiatric complaints are
unable to accurately or thoroughly describe their medical history,
baseline condition, or events leading up to their arrival at the
hospital. Thus, it becomes imperative to contact those who might
know the patient best or were in the patient’s company prior to
their arrival. Contact information can be obtained from the
patient themselves, persons accompanying the patient, or the
medical record. When initiating contact, confirm the other
person’s identity before revealing the patient’s name or the
reason you are speaking with them. If you reach voicemail and
the answering machine does not clearly identify the person you
are looking for, do not reveal any information about the patient –
simply state your name, number, position, and whom you are
requesting a callback from.
The policy document on collateral information offers advice to staff

about how to
(A) gather information from colleagues about specific patients.

(B) collect information about patients from their friends and
relatives.
(C) inform patients and their carers about recent diagnoses over the
phone.
Page 32
3. Assessing and Managing Peripheral Arterial Disease
Staff should assess patients who have symptoms suggestive of

peripheral arterial disease or diabetes with non-healing wounds
for the presence of peripheral arterial disease.
Ask about the presence of intermittent claudication and

critical limb ischaemia
Examine the lower limbs for evidence of critical limb
ischaemia
Examine pulses in the lower limbs: femoral, popliteal and feet
Measure the ankle brachial pressure index
Imaging is possible for patients with peripheral arterial disease:

duplex ultrasound is the first-line imaging technique. If patients
require additional imaging, contrast-enhanced magnetic
resonance angiography is used. If this is contraindicated or not
possible, use computed tomography angiography instead.
Lifestyle changes are the first-line treatment for peripheral

arterial disease, this includes: smoking cessation, better control
of diabetes, better management of hypertension, management of
high cholesterol, in combination with antiplatelet drugs. Finally,
regular exercise has shown to beneficially revascularise tissues
in those with claudication.
When dealing with patients with symptoms of peripheral arterial disease,

staff should
(A) look for signs of swelling in the upper body.

(B) confirm that the patient has a history of poor diet.
(C) identify the cause through physical examination and tests.
Page 33
4. Guidelines: Alcohol Withdrawal Treatment
Alcohol withdrawal can present as a life-threatening emergency
and requires treatment at a hospital. Providers use algorithms to
determine when and how much medication to administer for a
safe and optimal outcome. A key component of this assessment
is determining the severity of alcohol withdrawal using the
Clinical Institute Withdrawal Assessment for Alcohol (CIWA-
Ar). The scale contains 10 subjective and objective items that
can be queried and scored in minutes. Symptoms asked about
include nausea, vomiting, tremors, sweating, anxiety, agitation,
tactile/auditory/visual disturbances, headache, and cognitive
dysfunction. Every hospital has different cutoffs for treatment,
but as a general rule, treatment with benzodiazepines begin
starting at a score 8–10, with higher scoring indicating increasing
amount and frequency of medication.
The guidelines on alcohol withdrawal treatment informs healthcare

professionals about
(A) determining the quantity of medication required.

(B) reducing the dosage as the symptoms improve.
(C) various types of drugs to prescribe to patients.
Page 34
5. For the attention of all staff:
RE: AGITATED PATIENTS

Agitated patients are a common occurrence in the Emergency
Department. There are many reasons for agitation, ranging from
medical conditions, substance intoxication, psychiatric illness,
and distressing circumstances. While both physical and chemical
restraints are available to providers, these are items of last resort
as their use creates significant risk to the patient, staff, and other
persons in the area. Verbal de-escalation is a proven, effective
technique that can be used to calm a patient down and promote a
safe treatment environment. When de-escalating, designate one
person to speak for the group. Agitated patients can be easily
confused by multiple speakers and a unified message must be
presented. Respect personal space to prevent the patient from
feeling ‘trapped’ and maintain sufficient distance to avoid any
resultant physical aggression. Remember to introduce yourself
and your role on the treatment team to the patient. Use their
name and orient them to their surroundings and why they are
here in the hospital.
The memo is advising staff dealing with agitated patients on how to
(A) identify the cause of the agitation.

(B) avoid adding to the feelings of agitation.
(C) deal with violent behaviour caused by the agitation.
Page 35
6. Extract from Appropriate Treatment for Pain
Pain is one of the most common complaints that will be brought

to a physician’s attention. This section will cover treatment of
mild to moderate pain without the use of opioids. More severe
pain may require judicious use of short-acting opioid
medications or a consult to pain medicine. For most patients, the
first line medications for pain are acetaminophen and ibuprofen.
Maximum daily dosage of acetaminophen is suggested to be 4
grams, reduced to under 2 grams for patients with liver issues
such as a cirrhosis. Ibuprofen is particularly effective in patients
whose pain is caused by inflammation, though caution is urged
in elderly patients, patients with diagnosed bleeding issues
(especially gastrointestinal bleeds), or any cardiac issues.
Maximum daily dosage suggested is 2.4 grams. A combination
of acetaminophen and ibuprofen can be used if either one used
alone is not sufficient. For more localised pain relief, consider
using lidocaine dermal patches over non-broken areas of skin.
The guidelines advise that patients with heart problems
(A) may need to avoid ibuprofen.

(B) should be given lidocaine for pain relief.
(C) must receive a lower dose of acetaminophen.
Page 36
Reading Part C
TEXT 1: SYNTHETIC VOICES
There are many reasons why a patient may lose their voice; indeed, many of
us will already have experienced partial loss of voice, when suffering from a
cold or flu. While we tend to dismiss a hoarse voice as a mild annoyance,
when permanent voice loss occurs, it can be tremendously difficult for the
patient to deal with, both practically, and emotionally. When our voice works,
we don’t spend too much time thinking about what like would be like without
it, but the truth is that our voice is an integral part of who we are. Our voices
define us, they allow our loved ones to identify us over the phone, or when
visibility is poor. They distinguish us as individuals from certain parts of the
world, and they can even indicate our social standing. Until recently, patients
who experienced permanent loss of voice would have had relatively few
options at their disposal. However, as technology advances, the range

of speech replacement options available becomes increasingly
sophisticated. Today, synthetic voices are the most common type of
speech replacement device used by those who have permanently lost
their voice. The technology used to create this software can also be
seen in speech controlled home devices, and modern smartphones. As
permanent loss of voice is often caused by respiratory issues resulting
from other illnesses, however, it’s important that speech replacement
devices for those who have lost their voice take the patient’s other
disabilities into account. Speech-to-text systems typically involve a
system of levers or a simplified keyboard; the latter tends to be easier
for those with limited mobility to operate. Users are able to manipulate
these controls in order to select words from a computer interface and
build them into sentences. Some systems can also operate via eye
movement alone, so that when a user stares at a particular word on
the screen for a certain amount of time, it is selected.
Page 37
These systems show a remarkable advancement from one of the earliest
speech-to-text mechanisms designed in the sixties: a typewriter operated
through an air pipe, known as a sip and puff typewriter. The first electrical
communication device for disabled people who could not speak, a sip and
puff typewriter called the POSM (Patient Oriented Selector Mechanism), was
developed by Reg Maling, a volunteer at a hospital for paralysed people, after
he discovered that patients at the hospital who had lost the use of their voice
were only able to communicate using a bell. Throughout the rest of the
twentieth century, these technologies were gradually developed, and in the
1970s, the first portable, commercially available, adaptive alternative
communication devices (or AACs), were produced. Although they were
advertised as portable, these devices often weighed a hefty 15 – 20 pounds,
and tended to range from 20 to 25 inches in size. As many of the early portable
AAC users also used a wheelchair, in which it was relatively
straightforward to design a holster at the back of the chair to store
these devices.
Thankfully, the technology continued to develop, and devices became

smaller, easier to use and more sophisticated.In the United States
there are now over two million people who rely on such devices in their
day-to-day communications, yet many users still have to make do with
a limited number of vocal choices—often less than a dozen, with the
majority of available voices sounding adult and/or male. This is
extremely problematic, as users need to choose a voice that they feel
represents who they are. Proponents of new digital voice banks are
working toward raising the bar by steadily widening the scope for
self-expression among the many millions of diverse users of AACs.
Page 38
If patients are gradually losing their voice, but still able to speak, they may be
able to record their own voice to use with their AAC. Another alternative open
to patients is to make use of the increasing number of voices being donated.
Although voice donation does not require the contributor to physically give a
part of themselves away, as is the case with classic medical donations,
donators certainly must go the extra mile. The process of voice donation is
much more extensive than, say, donating a kidney, or other physical organ.
While the donation of an organ requires a relatively short stay in hospital, to
donate a voice requires many weeks of donor commitment. Donors must
speak many thousands of preselected words, phrases and sentences into a
recording microphone. Some companies offer a service tailored to the user,
who can read science fiction or fantasy stories out loud—or texts according to
their interests—in order to remain more engaged in the process.
Once a voice has been comprehensively recorded, it then becomes part of the
software for AACs, and made available to any patient that needs it. Professor
Stephen Hawking, the famous Cambridge physicist, began to use an early

text-to-speech system in 1986 called CallText. Interestingly, the professor
never changed his synthetic voice to a more sophisticated design that better
imitated natural speech. Instead, Hawking retained CallText, explaining that
he felt the limited modulations of the voice allowed his speech to be easier to
hear and understand during lectures. Clearly, Hawking also came to see it as a
part of his identity. 30 years after he began using CallText, the software was
nearing breakdown, but rather than simply replace it, he had a team of
researchers reverse engineer the voice onto a more modern platform.
Page 39
Take 5 minutes to answer questions 1 – 4. Time yourself.
1. In the first paragraph, the writer suggests loss of voice is difficult for
patients because it is
(A) part of their identity.

(B) necessary for interaction.
(C) used to form relationships.
(D) an indicator of social class.
2. Why does the writer believe it is important that speech replacement

devices be operated by a variety of methods?
(A) The technology should be kept up to date.

(B) Patients often suffer from various conditions.
(C) Healthcare workers might also need to use them.
(D) The devices should be usable across a range of platforms.
3. In the third paragraph, we lean that Reg Malling developed the POSM
due to
(A) the number of people who had permanently lost their voice.
(B) the lack of accessibility in previous sip and puff designs.
(C) the limited communication options for disabled people.
(D) the recent development of similar sound technology.
4. According to the writer, why were early portable AACs problematic for
those not in wheelchairs?
(A) They were heavy and bulky.

(B) They were remarkably fragile.
(C) They could not be used while walking.
(D) They needed access to a power source.
Page 40
Exercise
Take 2 minutes and 30 seconds to answer questions 5 – 6. Time
yourself.
5. The writer uses the phrase ‘raising the bar’ to underline the
(A) complexity of modern devices.

(B) need for a diverse range of voices.
(C) high quality of the sound recordings.
(D) number of new communication systems.
6. What is suggested about voice donation by the phrase ‘go the extra
mile’?
(A) donation centres are often far away

(B) a large number of voices are rejected
(C) donators sacrifice more than organ donators
(D) the process is extremely time-consuming
Page 41
Exercise
yourself.
7. In the fifth paragraph, the word ‘user’ refers to
(A) healthcare workers who treat loss of voice.

(B) patients with permanent loss of voice.
(C) AAC technology developers.
(D) voice donators.
8. What does the word ‘it’ refer to in the final paragraph?
(A) A presentation given by the professor.

(B) The research carried out for the professor.
(C) The synthetic voice used by the professor.
(D) The permanent loss of voice of the professor.
Page 42
Reading Part A: Practice Set
TIME: 15 minutes
Look at the four texts, A – D, on pages 78 – 81.

Anaemia: Questions
Questions 1 – 6
For each question below, decide which text (A, B, C or D) the

Page 14
Anaemia: Texts
TEXT A
Anaemia is defined as an overall decrease in red blood cell mass. There

are many varying causes of anaemia, which all present with some
general symptoms. Anaemia results in a lack of red blood cells in the
blood. Because it is the haemoglobin in red blood cells that carries
oxygen from the lungs to the rest of the body, a decrease in red blood
cells results in less oxygen going into the tissues. This causes a state
known as hypoxia, or reduced oxygen in body tissues.
The common symptoms of all anaemias are those of hypoxia:
Weakness, fatigue, difficult or laboured breathing

Pale skin
Headache and light-headedness
Chest pain (if the patient already has a disease of the arteries
supplying the heart)
Page 15
The fourth item in SPIKES is giving knowledge to the patient. You should be
direct, but avoid being unfeeling or blunt when you discuss their condition, and
utilise non-technical terms in small chunks. Prognosis and course of illness
should be realistic, but also convey hope and planning for the future. An
appropriate opening for our patient would be, “I’m afraid, we have some serious
news about the CT scan that was performed. It showed that the cancer in your
liver has spread to your spine.” Take note of how the words ‘hepatocellular
carcinoma’ and ‘metastasis’ were rephrased into layman’s terms.
The fifth item in SPIKES is addressing the patient’s emotions. You should
identify the emotion the patient is experiencing, the reasoning, and provide
support during this difficult time. Don’t try to change the patient’s emotions, just
help them to express how they feel. For example, in a patient who is dysphoric
and crying, you can offer a tissue box and physical support if appropriate. You
might say something like, “I know these results weren’t what you wanted to
hear. I wish we had better news for you.” Other responses can range from asking
the patient to elaborate on their reaction, “Can you tell me what you’re worried
about?” to validating their concerns, “I can understand why you felt that way.
Many other patients have had similar reactions.”
The sixth item in SPIKES is strategy and summary. Patients who

receive serious news will often feel that they are in over their head, so
you should make sure that they leave with a clear plan for the future.
This will help them to feel less anxious and more hopeful. Patients
should know what options are available for them and what follow-up is
planned. You should also recheck that they understand what has just
been discussed and have had all their questions answered. A good
opening statement could be, “I understand this is a lot to take in, but
you have several options available. A decision does not need to be
made now, but we would like to refer you to an oncologist and follow-up
with us in a week to discuss your next steps.” Giving serious news is
one of the most difficult parts of being a healthcare professional.
However, with careful planning and an effective protocol, patients can
leave feeling well-informed and in control of their own outcome.
Page 45
1. Why does the writer prefer the term ‘serious news’?
(A) It enables doctors to avoid unnecessary conversations.

(B) It avoids influencing the patient’s emotional response.
(C) It helps patients to better understand their condition.
(D) It offers a more specific definition of the information.
2. The writer’s purpose in the second paragraph is to highlight
(A) the treatment options available to most patients.

(B) the difficulty of knowing what a patient wants to be told.
(C) the trends concerning what patients and relatives want to hear.
(D) the different topics that healthcare workers should cover with
patients.
3. What does the word ‘those’ refer to?
(A) healthcare staff

(B) treatment experts
(C) language translators
(D) patients and relatives
4. In the fourth paragraph, the writer mentions the patient, Harry, in order
to explain that
(A) patients are often reluctant to ask for help.

(B) patients may not be aware of their ignorance.
(C) healthcare professionals often find it hard to relate to patients.
(D) healthcare professionals may not always explain things
effectively.
Page 46
5. The writer suggests that older patients may be more likely to
(A) require more information.

(B) limit their family’s involvement.
(C) accept the staff’s suggested plan.
(D) inquire further about their treatment plans.
6. In the sixth paragraph, the writer offers an example to emphasise that
when explaining information professionals should
(A) avoid using complex medical language.

(B) prevent patients from becoming upset.
(C) discuss how the illness was identified.
(D) repeat information multiple times.
7. The seventh paragraph focuses on
(A) ensuring the patient understands how to react.

(B) helping the patient to feel more positive.
(C) comparing different patient responses.
(D) empathising with the patient’s reaction.
8. The expression ‘in over their head’ is used to stress that patients might
(A) find the information overwhelming.

(B) struggle to remember information.
(C) make a choice about their treatment quickly.
(D) have difficulty understanding their prognosis.
Page 47
QUESTIONS 9 TO 16
In this part of the test, there are two texts about different aspects of
healthcare. For questions 9 to 16, choose the answer (A, B, C or D)
which you think fits best according to the text.
TEXT 2: TREATING OPIUM ADDICTION

In the United States alone, there are around 115 deaths caused by opioid
addiction every day. The addiction impacts individuals rapidly and drastically,
damages families, and costs the US huge amounts of money: the total economic
burden of prescription opioid abuse is estimated to be $78.5 billion a year, while
the economic burden of non-prescription opioid abuse simply cannot be
calculated. Measures are constantly being improved to prevent patients from
developing opioid addictions to begin with, but it is also imperative that we
continue to provide treatment for those already in the thrall of opioid addiction.
Jane’s story is one heard over and over again in opioid addiction clinics. When
she was 20, she had a bad automobile accident that required two surgeries. She
was soon home from the hospital but her residual pain meant she was prescribed
scheduled opiates. Jane’s body soon became tolerant of the dosage; however, and
she needed higher and higher doses in order to achieve the same pain relieving
effect. She eventually reached a level that her physician felt uncomfortable
prescribing. Unable to find another prescriber in time, Jane turned to alternative
sources of narcotics. Unfortunately, when purchased on the street, these pills are
exorbitantly expensive and increasingly hard to come by in an era of prescription
monitoring throughout the United States. Heroin is much cheaper and,
when delivered by IV, produces a much more potent high and greater
pain relief.
Page 48
Eventually, after destroying relationships with her loved ones, bankrupting her
savings, and hitting rock-bottom, Jane turned to a local opioid addiction clinic
for help. At the clinic, they put her on Methadone, a long-acting opioid agonist
that is standard for addiction treatment. It binds to the mu-opioid receptors,
prevents withdrawal symptoms, reduces cravings, and can also provide a level of
pain relief. Of course, as an opioid agonist, methadone serves as a substitute for
the primary addiction, meaning many of the issues associated with long-term
opioid usage remain. Patients must often begin treatment with daily visits, which
can be disruptive. Fortunately for Jane, these visits are her first steps towards
putting her life back together. As Jane’s road to recovery is likely to be long and
fraught with difficulty, many doctors are led to wonder: does she have any other
options?
One of the increasingly popular alternatives to methadone is buprenorphine, a

partial mu-opioid agonist. Aside from its unique mechanism of action (MOA),
there are two major differences when compared to Methadone: first, it can be
administered as oral tablets, sublingual/buccal films, and a long-acting implant,
second, It can be prescribed month-to-month from a clinician’s office directly to
a local pharmacy. These factors make it much easier to use in the community,
and are ideal for patients who cannot visit a methadone clinic every day.
To initiate buprenorphine, a patient must already be in a mild state of withdrawal

due to the high affinity for the mu-opioid receptor displacing other opioids. This
means that patients generally transition best from a short-acting opioid like
heroin or oxycodone rather than a long-acting opioid agonist like Methadone,
given the length of time needed until mild withdrawal occurs. As Jane had been
using opioids for a long time prior to her admission, however, she was better
Page 49
suited to treatment with Methadone, as there is no ceiling effect to this drug, and
Jane had developed a high tolerance to opioids. Buprenorphine, being a partial
agonist, has a maximum level of effect which it cannot be increased beyond. For
this reason, buprenorphine can be used as a maintenance therapy in some
patients, but it can also be tapered down over time. This allows patients to
resume their normal lives with minimal interruptions and avoid relapse through
pharmacological blocking.
Alongside treatment with medication, patients recovering from opioid addiction

must also deal with recovery at a mental level. As with many healing processes,
the first stage is acceptance. Jane was not able to seek the treatment she needed
until she had nowhere else to hide. Once everything was lost, she couldn’t deny
that she was in trouble anymore, so she came to the clinic. Many patients
suffering from opioid addictions are reluctant to admit that they are addicted, and
reluctant to ask for help. Patients are often worried about being judged, being
treated like a criminal, and meeting with disapproval from the healthcare
professionals who must treat them.
When patients do seek aid, healthcare professionals need to help them to build a
support network around themselves, so that they are protected when they feel the
need to relapse. Opioid addicts are likely to have burned bridges with friends and
family who have not enabled their addiction, so patients beginning recovery may
not have positive role models to support and influence their recovery. Talking
therapies, such as cognitive behavioural therapy (CBT) can be offered to
recovering patients experiencing anxiety or depression, though patients may find
it more useful to join local confidential support groups, such as Narcotics
Anonymous, as they can discuss recovery with those who have first-hand
experience. Though Jane was hesitant to discuss her experiences with anyone
when she was first admitted to the clinic for treatment, she has since gone on to
attend weekly sessions at Narcotics Anonymous, where she not only listens to
others share their stories of recovery, but where she also is beginning
to tell her own.
Page 50
9. In the first paragraph, the writer highlights that opioid addiction in the
US
(A) has been gradually increasing for a number of years.

(B) is largely influenced by the illegal sale of drugs.
(C) causes more deaths than any other addiction.
(D) has a significant financial and social impact.
10. In the second paragraph, the writer outlines Jane’s case in order to
emphasise that
(A) opioid addiction is increasingly rare.

(B) it can be remarkably easy for a patient to become addicted.
(C) in some cases, heroin is less harmful to addicts than opioids.
(D) healthcare professionals must take responsibility for opioid
addiction.
11. The writer uses the phrase ‘hitting rock bottom’ about the patient Jane
in order to describe
(A) how her addiction led to the most distressing point in her life.
(B) her sudden awareness that she had to recover.
(C) the large tolerance she developed for opioids.

(D) the physical pain she felt at that time.
12. In the fourth paragraph, the writer suggests that buprenorphine may be
preferable because
(A) it is less addictive than alternatives.

(B) it can be easier for patients to access.
(C) it does not interfere with other treatments.
(D) it can be picked up more often than other medications.
Page 51
13. What does ‘this means that’ refer to?
(A) The effectiveness of buprenorphine when combating opioid

displacement.
(B) The requirement for the medication to be reserved for heroin
addicts.
(C) The need for patients to have begun to experience withdrawals.
(D) The impact of mu-opioids on recovered opioid addicts.
14. In the fifth paragraph, the writer suggests that Jane was prescribed
methadone, rather than buprenorphine because
(A) buprenorphine is too similar to heroin.

(B) the effects of methadone last for longer.
(C) she was dependent on high doses of opioids.
(D) it is more readily available at addiction clinics.
15. According to the seventh paragraph, why do patients often delay seeking
treatment for opioid addiction?
(A) They are unwilling to face the damage they have caused.
(B) They do not realise they are addicted until it’s too late.
(C) They think that they can recover without help.
(D) They do not want to be labelled as an addict.
16. In the final paragraph, the writer suggests that recovering addicts may
prefer to discuss their experiences with
(A) those who have experienced addiction.

(B) people who are not aware of their history.
(C) healthcare professionals.
(D) friends and family.
Page 52
TEXT C
While there are many different causes of anaemia, laboratory studies and unique
features of the patient can be used to help differentiate between various
aetiologies.
Laboratory studies used to diagnose anaemia include:

Haemoglobin (Hb)—a measure of the protein that transports oxygen in the
red blood cell
Haematocrit (Hct)—a measure of the percentage of red blood cells in the
blood
Red blood cell amount (erythrocyte count)—a measure of the number of red
blood cells in the blood
A general diagnosis of anaemia can be determined by the following values:
Haemoglobin level
Males: less than 13.5 g/dL
Females: less than 12.5 g/dL (women have a generally lower haemoglobin
because of blood loss during the monthly menstrual cycle)
Haematocrit
Males: less than 45% red blood cells
Females: less than 37% red blood cells (women have a generally lower
haematocrit because of blood loss during the monthly menstrual cycle)
Red blood cell amount

Male: less than 4.7 million cells/mL
Female: less than 4.2 million cells/mL (women have a generally lower red
blood cell amount because of blood loss during the monthly menstrual
cycle)
While these laboratory tests are good estimates of the red blood cell mass, they
are not perfect. Red blood cell mass is very difficult to measure, and therefore
these laboratory tests are used together to assess whether or not someone has
anaemia. Page 17
PRACTICE SET
1. D
2. A
3. C
4. B
5. C
6. B
---------------------------------------------------------------------------------------
7. fortified foods (and supplements)

8. low reticulocytes (reticulocytopenia)
9. laboured
10. 45
11. reticulocytes (reticulocytosis)
12. menstrual cycle
13. complications
14. size of the red blood cell
---------------------------------------------------------------------------------------
15. blood loss

16. disease of the arteries
17. bone marrow
18. Red blood cell mass
19. iron deficiency
20. unique features
Page 54
Part b
1. A duty to care for a patient continues after a referral.

2. C should only be used on patients as a last resort.
3. A seeking advice from others.
---------------------------------------------------------------------------------------
4. C They must be destroyed after use.

5. B prevent a scab from forming.
6. C who have a particular genetic makeup.
7. A are caused by surgery.
---------------------------------------------------------------------------------------
8. C what to do before administering an IV.

9. B aware that even minor illnesses can be distressing for parents.
10. C Inform patients of the changes to be implemented.
---------------------------------------------------------------------------------------
PRACTICE SET
1. B to prolong the effects
2. B collect information about patients from their friends and relatives.
3. C identify the cause through physical examination and tests.
4. A determining the quantity of medication required.
5. C deal with violent behaviour caused by the agitation.
6. A may need to avoid ibuprofen.
Page 55
Part c
1. A part of their identity.

2. B patients often suffer from various conditions.
3. C The limited communication options for disabled people.
4. A They were heavy and bulky.
-------------------------------------------------------------------------------------
5. B need for a diverse range of voices.

6. D the process is extremely time-consuming.
-------------------------------------------------------------------------------------
7. D voice donators.
8. C the synthetic voice used by Stephen Hawking.
-------------------------------------------------------------------------------------
Questions 1 to 8
1. B It avoids influencing the patient’s emotional response.
2. C the trends concerning what patients and relatives want to hear.
3. D patients and relatives
4. B patients may not be aware of their ignorance.
5. C accept the staff’s suggested plan.
6. A avoid using complex medical language.
7. D empathising with the patient’s reaction.
8. A find the information overwhelming.
Questions 9 to 16
9. D has a significant financial and social impact.
10. B it can be remarkably easy for a patient to become addicted.
11. A how her addiction led to the most distressing point in her life.
12. B it can be easier for patients to access.
13. C The need for patients to have begun to experience withdrawals
14. C she was dependent on high doses of opioids.
15. D They do not want to be labelled as an addict.
16. A those who have experienced addiction.
Page 56
2
Kaplan Practice Test
Page 57
THE PRACTICE TEST
Reading Section
TIME: 15 minutes
Look at the four texts, A – D, in the Text Booklet.

PART A: QUESTIONS 1 TO 20
Asthma: Questions
Questions 1 – 6
For each question below, 1 – 6, decide which text (A, B, C or D) the

In which text can you find information about
Page 58
ASTHMA: TEXTS
Text A
Establishing the severity of an acute asthma attack
Moderate asthma Severe asthma Life-threatening

asthma
Adults Measure PEF and arterial saturation
PEF >50-75% predicted PEF 33-50% PEF <33% predicted

predicted
SpO2 ≥92% SpO2 ≥92% SpO2 ≥92%

PEF > 50-75% predicted PEF < 50% silent chest
No features of acute severe predicted cyanosis
asthma RR ≥ 25/min poor respiratory
HR ≥ 110/min effort
difficulty talking arrhythmia
hypotension
exhaustion
altered
consciousness
Asthma sufferers of any severity may also experience the following:
shortness of breath
coughing
tightness or pain in the chest

a whistling sound when exhaling
Page 59
TEXT B
Lung Function Tests in Asthma
Asthma tests should be undertaken to diagnose and aid management of the
condition. This is particularly important in asthma, because it presents slightly
differently with each patient. Spirometry is the most important test, however
several different types of test are available:
Peak expiratory flow rate (PEFR): this is the maximum flow rate during
exhalation, after full lung inflation. Diurnal variation in PEFR is a good
measure of asthma and useful to the long-term management of patients and
the response to treatment. Monitor PEFR over 2-4 weeks in adults if there is
uncertainty about diagnosis. It is measured with a peak flow meter - a small,
handheld device - into which the patient blows, giving a reading in l/min.
Spirometry: measures volume and flow of air that can be exhaled or inhaled
during normal breathing. Asthma can be diagnosed with a >15%
improvement in FEV1 or PEFT following bronchodilator inhalation.
Alternatively, consider FEV1/FVC < 70% as a positive result for obstructive
airway disease. A spirometry test usually takes less than 10 minutes, but will
last about 30 minutes if it includes reversibility testing.
Direct bronchial challenge test with histamine or methacholine: in
this test, patients breathe in a bronchoconstrictor. The degree of narrowing
can be quantified by spirometry. Asthmatics will react to lower doses, due
to existing airway hyperactivity.
Exercise tests: these are often used for the diagnosis of asthma in
children. The child should run 6 minutes (on a treadmill or other) at a
workload sufficient to increase their heart rate > 160/min. Spirometry is
used before and after the exercise - an FEV1 decrease > 10% indicates
exercise-induced asthma.
Allergy testing: can be useful if year-round allergies trigger a patient’s
asthma. This will be recommended if inhaled corticosteroids are not
controlling symptoms. Three different tests are used to measure the patient’s
reaction to allergens: nitric oxide testing, sputum eosinophils and blood
eosinophils.
Page 60
TEXT C
Patients with asthma of any severity may find their attacks panic-inducing.
Remember that the patient’s struggle to breathe can cause stress, panic and a
feeling of helplessness. There is a strong link between people who suffer from
asthma and those who experience panic attacks. Staff must keep this in mind
when treating patients with asthma, as some sufferers will require additional
emotional support.
Patients may find breathing exercises beneficial. Advise patients to practice

daily, to allow these exercises to become habitual. When experiencing an attack,
patients should make a conscious effort to relax their muscles and maintain
steady breathing. Advise patients to breathe deeply in through the nose and out
through the mouth.
Smokers are at a higher risk of developing both panic attacks and asthma. In
addition, smoking can irritate the airways in patients with asthma, causing
neutrophilic inflammation, and exacerbating breathing problems in those with
asthma. Ensure that patients who smoke are fully aware of the risks of smoking
with asthma.
Page 61
TEXT D
Management of Acute Asthma

Rapid treatment and reassessment is of paramount importance. It is sometimes
difficult to assess severity. Maintaining a calm atmosphere is helpful to resolving
an acute asthmatic attack.
Page 62
1. relaxation techniques for those suffering from an asthma attack?
2. measuring the respiration abilities in patients with asthma?

3. identifying the intensity of asthma attacks in patients?
4. the procedure to follow when treating an asthma attack?
5. symptoms of asthma in patients?
6. how to diagnose asthma in patients?
Questions 7 – 12
Complete each of the sentences, 7 – 12, with a word or short phrase

from one of the texts. Each answer may include words, numbers or
both. Your answers should be correctly spelled.
7. To understand how severe an asthma attack is, (7) must be

measured, in addition to PEF.
8. For patients who do not respond to therapy, an IV of (8) can
be used to treat severe asthma attacks.
9. Nitric oxide testing can be used to determine (9) in patients.
10. A patient suffering from arrhythmia and a peak expiratory flow of

greater than 33% would be diagnosed with (10) asthma
attacks.
11. Spirometry tests that contain (11) typically last for half an
hour.
12. (12) can cause neutrophilic inflammation in patients with

asthma.
Page 63
Questions 15 – 20
Complete the sentences below by using a word or short phrase from
the text. Each answer may include words, numbers or both.
15. Anaemia caused by (15) should be treated with a blood

transfusion.
16. Patients suffering from hypoxia and chest pain are likely to also have a
(16) .
17. If (17) is functioning properly, high reticulocyte anaemia is

likely to be present.
18. A number of tests may be necessary to diagnose anaemia, due to the

difficulties involved in measuring (18) .
19. Patients with anaemia caused by (19) should be instructed to

adjust their diet.
20. When identifying the type of aetiology, (20) of the patient

should be considered, in addition to laboratory studies.
Page 20
PART B: QUESTIONS 1 TO 6
End-of-Life Decision Making

1. Remember the five priorities when caring for a dying patient:
Recognise that the end of life may be approaching.

1. Communicate with patients, families, carers and staff.
2. Involve patients and those close to them in decision-
3. making.
Support the needs of families and carers.
4. Develop an individualised plan of care for the patient.
5.
An end-of-life care plan must ensure the physical, psychological,
social and spiritual comfort of the patient, and should strive for
the best possible quality of life for the patient’s remaining time.
This includes prescribing anticipatory medications which can be
given as required, falling under the following categories which
staff are encouraged to remember as the ‘Four As’: Analgesia
(pain relief), Anxiolytics (anti-anxiety), Anti-emetics (for nausea
and vomiting), and Anti-secretory (for respiratory and airway
secretions). Any unnecessary medications, such as long-term
diabetes control and blood pressure medications can be stopped.
A Do-Not-Resuscitate (DNACPR) decision also needs to be
made.
The notice reminds staff that patients who are dying
(A) will need to be prescribed anti-emetics.

(B) might not need to continue with certain medication.
(C) should be encouraged to discuss their condition with loved
ones.
Page 65
2. Anaesthesia use at Harlow Dental Centre
At this practice, preference is given to the use of local

anaesthetics in combination with conscious sedation.
Many local anaesthetics may be used in order to reversibly block

specific pain pathways and/or cause paralysis of muscles. The
most commonly used local anaesthetic at the centre is lidocaine -
remember that the half-life of lidocaine in the body is about 1.5
to 2 hours. Other local anaesthetic agents include articaine,
bupivacaine, prilocaine and mepivacaine. Often, a combination
of local anaesthetics may be used, sometimes with adrenaline or
another vasoconstrictor to modulate the metabolism of the local
anaesthetic and control local bleeding.
Sedation during procedures should mostly be limited to

conscious sedation. Benzodiazepines enhance the effect of
neurotransmitter gamma-aminobutyric acid (GABA) at the
GABAA receptor. This results in a sedative, hypnotic, anxiolytic,
anticonvulsant and muscle relaxant properties.
The guidelines inform us that multiple anaesthetics can be used
(A) to increase the numbing effects.

(B) to prevent bleeding throughout the procedure.
(C) to more accurately control how long it will last.
Page 66
Reading Part B
Continuity and coordination of care

1. All healthcare professionals must be involved in the safe transfer
of patients between each other and social care providers. This
includes:
Sharing all relevant information with colleagues that are
involved with your patient’s care, both inside and outside the
team, including when the care handover is done at the end of
duty, and when care is delegated or referred to other health or
social care providers.
When possible, check that a named team or clinician has
appropriately taken over responsibility when your role has
ended in providing a patient’s care. This is most important in
vulnerable patients who do not have capacity.
When care is transferred or delegated to another healthcare
professional, it is your responsibility to ensure that the person
providing care has the appropriate skills, qualifications and
experience to provide adequately safe care for the patient.
The policy document tells us that a healthcare professional’s
(A) duty to care for a patient continues after a referral.

(B) ability to look after a patient should be decided by superiors.
(C) obligation to check up on transfers does not apply to all
patients.
Page 21
4. Autism in Young People
More than 1% of the UK population has an autism spectrum

disorder. Signs can vary widely between individuals and at
different stages of an individual’s development. When children

present with other conditions such as ADHD (attention deficit
hyperactivity disorder) or other learning difficulties, autism
spectrum disorders often go undiagnosed.
In children with autism spectrum disorders, symptoms are

present before three years of age but diagnosis can be made after
this age too. Individuals with autism spectrum disorder tend to
have issues with social interaction and communication, including
difficulty with eye contact, facial expressions, body language
and gestures. Often, children with autism spectrum disorders
may lack awareness or interest in other children and tend to play
alone.
The causes of autism spectrum disorder are unknown but are

linked to several complex genetic and environmental
interactions.
This guidelines on autism in young people inform us that
(A) the disorder is more difficult to identify in patients with

ADHD.
(B) most children with autism are diagnosed before the age of
three.
(C) young people with autism are more likely to suffer from other
conditions.
Page 68
5. Subject: Fielding Patient Complaints
For the attention of all hospital staff:
At County Green Hospital, we endeavour to provide our patients

and families with the highest quality of services. Unfortunately,
there may be times where performance does not meet
expectation. We routinely survey our patients on how we can do
better, but members of the treatment team may also be
approached with patient feedback, so all employees must be
aware of the correct procedure for handling patient complaints.
The first step is to listen to what patients have to say and
document details appropriately. Whether or not you feel there is
a legitimate grievance, it is important to keep a record for later
examination. While listening to the complaint, the employee
should validate the patient or family member’s experience. This
does not mean there needs be agreement about the nature of the
complaint, but that the employee demonstrates a clear
understanding of why the patient or family member might be
feeling this way.
The memo reminds all staff to avoid
(A) challenging a patient’s criticisms.

(B) handling grievances of a sensitive nature.
(C) recording complaints that are not legitimate.
Page 69
2. Assessing Physical Restraints
We first advise providers to verbally de-escalate and offer

medications as a method of calming an agitated patient down.
However, if these do not work and the patient becomes violent, a
standard protocol for physical restraints should be followed.
Trained personnel should carry out the actual action of
physically restraining the patient and a bed with restraints should
be prepared ahead of time. Medications should be drawn up in
IM form and be ready to be given once the patient has been
physically restrained. A physician should then assess the patient,
first debriefing staff on the situation that caused the patient to be
placed in restraints and then speak to the patient personally to
determine their understanding of the same events.
Cardiopulmonary status and restraint tightness must be assessed
and the patient’s level of pain and distress documented.
The guidelines inform us that physical restraints
(A) can only be administered to patients by qualified staff.

(B) must be applied before patients become aggressive.
(C) should only be used on patients as a last resort.
Page 22
PART C: QUESTIONS 7 TO 14
In this part of the test, there are two texts about different aspects of
healthcare. For questions 7 to 22, choose the answer (A, B, C or D)
which you think fits best according to the text.
Text 1: Work-Related Stress & Medical Errors
Stress is a term that crops up all too often in modern conversation, used to
describe every unfortunate circumstance, every out-of-sequence event, and every
foot out of line. What is stress? Most definitions of stress cover any internal or
external stimulus which results in a negative response or disturbance in one’s
physical, social or mental wellbeing. Unfortunately, stress is common, and it can
be devastating to people’s lives and health when it is maintained over long
periods of time, and when it gains the capacity to overwhelm one’s coping
abilities and mechanisms.
In the medical profession, daily stress is almost guaranteed. Recently, changes to

many healthcare workers’ contracts in the UK have resulted in longer and more
antisocial working hours, as well as an increased workload, greater bed crises in
hospitals and larger budget cuts, so stress levels amongst UK healthcare
professionals are on the rise. A 1996 questionnaire study in the Lancet reported
that 27% of doctors in the UK believed that the stress they experienced was
triggered by poor management, low job satisfaction, financial concerns, and
patients’ suffering, amongst other factors.
Page 71
Over two decades later, these problems still exist; some healthcare worker’s
argue that conditions have actually deteriorated. A 2013 report by the British
Medical Association stated that over 50% of UK doctors had experienced an
increase in work-related stress over the preceding year, in addition to an increase
in the complexity of their work. 25% of junior doctors in hospitals also reported
a reduced quality of care for patients due to high levels of stress and the
pressures put on individual members of staff, with levels of stress exacerbated by
longer working hours. In many healthcare jobs, stress is the elephant in the
room, particularly with junior staff, who may feel unable to voice concerns
about their workload. Unfortunately, however, these factors have the potential to
lead to medical mistakes, which could be detrimental to patient lives. In such a
circumstance, who is really to blame? The overworked medical staff, or the poor
management of modern hospitals?
We do not need to look far to examine the effect that stress can have on doctors
today. In 2015, Dr Hadiza Bawa-Garba was found guilty of manslaughter after
failing to provide life-saving treatment to a patient when needed, resulting in the
unfortunate death of a six-year-old child, Jack Adcock. In 2018, this experienced
senior paediatrician with a previously unblemished record was struck off the
medical register, unable to ever practice again as a doctor. The case of Dr Bawa-
Garba infuriated many in the medical profession, as fingers were pointed at an
overworked doctor working under immense pressure who was blamed for gross
negligence. But who is the truly negligent one in our current healthcare system?
While the death of young Jack is extremely saddening, it is important to explore
the circumstances around his death in order to prevent such tragedies from
reoccurring. On the day of the incident, Dr Bawa-Garba was covering her own
workload as well as that of two senior colleagues who were away, across six
wards, spanning four floors, with malfunctioning IT software and out-of-order
results systems. Did Dr Bawa-Garba make detrimental mistakes? Yes. But one
must ask, are we creating a recipe for disaster when we require our medical staff
to work under such immense pressures? Could this be one tragic event
of many waiting to happen? Such mistakes ruin lives.
Page 72
Studies have shown that the most common cause of medical errors is the use of
heuristics in medical decision-making, leading to bias. Heuristics are shortcuts
taken to reach decisions quickly, based on previous patterns of disease and
similar cases seen by the doctor. Mistakes are more likely when such shortcuts
are used by junior doctors who lack the experience necessary to make such fast
decisions accurately. Tversky and Kahneman outlined seven types of heuristics
in their 1974 article: Availability heuristics are based on how easy specific
diagnoses are to recall, resulting in over-diagnosis of rare but memorable
conditions; Representativeness heuristics are based on similarity of patient
presentations to previous typical cases, leading to delayed or missed diagnoses in
atypical or non-characteristic patients; Anchoring heuristics occur when a
diagnosis is based on one piece of information only, leading to rapid conclusions
which lack evidence and early diagnosis without consideration of all available
information; Confirmation bias occurs when a diagnosis is based on a pre-
conceived idea, where the doctor pays attention to the information that supports
their theory, and evidence which challenges the diagnosis is consciously or
subconsciously ignored; Commissioning bias where a doctor acts too soon rather
than waiting to gather and review all the information first; Gambler’s Fallacy
which is where consecutive patients have the same diagnosis and so the doctor
assumes a similar patient who follows must also have the same diagnosis;
Fundamental Attribution Error which is the tendency to blame patients rather
than their circumstances for their poor health.
Research shows that the best way to avoid medical errors in diagnosis is to
consider several hypotheses, known as “differential diagnoses”, and investigate
them all equally until the one with the most supporting evidence is found and
agreed upon. Use of heuristics and the resultant flawed decision-making could
be prevented by reducing work stresses and pressures on medical
professionals. One way to achieve this would be to reduce working
hours and shift durations in order to prevent sleep deprivation in
medical staff, which is known to hinder focus, thus creating a safer
medical environment for both staff and patients.
Page 73
7. The first paragraph explains that stress
(A) is usually caused by a factor than cannot be controlled.

(B) is interpreted in various ways by different people.
(C) is unusual when it lasts for an extended time.
(D) generally impacts people’s behaviour.
8. In the second paragraph, doctors are said to claim that stress
(A) is often improperly managed by chronic sufferers.

(B) could be improved by increasing the welfare budget.
(C) generally resulted in their having to work longer hours.
(D) was caused by a number of issues including money worries.
9. The writer uses the phrase ‘the elephant in the room’ to emphasise the
fact that
(A) levels of stress experienced by staff has declined.

(B) senior staff generally experience less stress than their juniors.
(C) many healthcare professionals do not discuss the stress they
experience.
(D) junior doctors have reported a lower quality personal life as a
result of stress.
10. Why does the writer comment on Dr Hadiza Bawa-Garba and her patient
Jack?
(A) to suggest that doctors are more likely to make significant
errors when stressed
(B) to outline a scenario where a doctor’s concerns about stress
were ignored
(C) to demonstrate that stress in healthcare professionals is
unacceptable
(D) to emphasise the impact the death of a patient can have on
stress
Page 74
11. The writer suggests that Jack Adcock’s death was partly caused by
(A) technology that was out of date and faulty.

(B) a hospital ward overcrowded with patients.
(C) an insufficient number of nursing team staff.
(D) a lack of experience among the clinical team.
12. Why might doctors who use heuristics be at a greater risk of making
clinical errors?
(A) heuristics are more likely to be used by junior doctors

(B) doctors might take too long to complete their tasks
(C) doctors might skip over the relevant information
(D) the different types of heuristics are confused
13. The writer claims that confirmation bias might cause doctors to ignore
relevant information if
(A) they have recently treated a patient with the same condition.
(B) they are very familiar with the evidence being presented.
(C) the patient displays extreme symptoms.
(D) it does not support their existing theory.
14. What does the word ‘them’ refer to in the final paragraph?
(A) the team of healthcare staff

(B) a variety of possible causes
(C) the mistakes in patient care
(D) a number of different texts
Page 75
QUESTIONS 15 TO 22
Text 2: Electroconvulsive therapy (ECT)
Electrodes. Wires. Bite Blocks. For many these terms bring to mind a sinister
mental asylum and the foreboding image of a patient about to suffer a tortuous
electric shock. Literature written in the 20th century did much to criticise this
practice, with writers frequently describing electroconvulsive therapy (ECT) as
faorm of torture, reserved for the most vulnerable members of society.
Interestingly enough, ECT has actually been used in the healthcare
field for hundreds of years. Before the advent of effective antipsychotic
medications, a wide variety of therapies were trialled for serious mental
illnesses. One of these involved the therapeutic use of inducing
seizures in patients. As early as Benjamin Franklin’s (1705 – 1790)
time, an electrostatic machine could be used to cure someone of
‘hysterical fits’. Through the 19th century, British asylums began to
employ electroconvulsive therapy in a widespread effort to cure
diseases of the mind. In the early 20th century, a neuropsychiatrist by
the name of Ladislas J. Meduna promoted the idea that schizophrenia
and epilepsy were antagonistic disorders, and that precipitating
seizures could serve as a potential treatment of schizophrenia. There
were several methods used to induce seizures, including insulin coma,
seizure-inducing medications (metrazol), and most famously, ECT.
While many of these practices are now seen as barbaric, there were
very few options for psychiatric treatment before the development of
antipsychotics, mood stabilisers, and anti-depressants. With the rise of
these new treatment options came an increase in the public awareness
of the often inhuman conditions of electroshock. The revelations
resulted in widespread backlash, and the use of ECT therapy began to
swiftly decline. However, in the later part of the 20th century, after
much debate and research, the National Institute of Mental Health in
the US came to a consensus that ECT was both safe and effective
when proper guidelines were implemented. In the US today, ECT
treatment is routinely covered by insurance for severe and
treatment-resistant forms of mental illness.
Page 76
The exact mechanism of action for ECT is unknown, but there are
several hypotheses: Firstly, increased release of monoamine
neurotransmitters such as dopamine, serotonin, and norepinephrine;
secondly, enhanced transmission of monoamine neurotransmitters between
synapses; thirdly, release of hypothalamus or pituitary gland hormones and
fourthly, anticonvulsant effect. ECT has several indications, the most notable
being refractory major depression, catatonia, persistent suicidality, and bipolar
disorder. It is also used in pregnancy as it is effective and does not have the
teratogenic effects of some other psychiatric medications. While there are no
absolute contraindications, it goes without saying that when using ECT, the
risks involved will carry more weight with certain patients. Those with
unstable cardiovascular conditions, those who have recently suffered a stroke,
and those with increased intracranial pressure, severe pulmonary conditions, or
a high risk in anaesthesia may not be suitable candidates for ECT. To further
explore the appropriateness of using of ECT on specific patients, consider the
following case study.
The patient, let’s call her Dana, is a 35 year old female who has a history of
schizophrenia. She was taken to the hospital by ambulance because her parents
found her motionless in her bed, staring blankly, not responding to external
stimuli, and not eating or drinking for two days. The psychiatrist caring for her is
understandably concerned, because this represents symptoms of catatonia. If
Dana does not eat or drink, she may develop life-threatening nutritional
deficiencies and electrolyte imbalances. If she does not move, Dana may end up
developing a blood clot that could result in a fatal pulmonary embolism. The
first-line treatment is benzodiazepines, but in this particular case, there is no
improvement in her condition. The psychiatrist decides that that ECT is the next
best option. There is the issue of informed consent. Legal jurisdiction handles
this differently throughout the world, but if a patient lacks capacity or is too ill to
provide consent, a court must provide substitute consent to ensure adequate legal
oversight. Once this happens, Dana is medically screened and prepped for
treatment.
Page 77
A course of ECT treatments does not have a standard regimen. Generally, most patients
require between six to twelve treatments, but the actual endpoint is determined by the level
of improvement. ECT is often given two to three times a week, usually on a
Monday/Wednesday/Friday schedule with psychiatric symptoms and testing carried out on a
regular basis to monitor progress. Dana starts Monday by being NPO (nothing by mouth)
except for any necessary medications. This reduces the chance for aspiration under
anaesthesia during the seizure. She will be taken down to the ECT suite where an
anaesthesiologist, psychiatrist, and nurse will greet her. She will be placed in a supine
position with EEG monitoring to determine the quality of the seizure given. She will have
electrodes placed on her head bitemporally, bifrontally, or unilaterally on the right. In this
case, given her life-threatening catatonia, we will use the bitemporal position. The
anesthesiologist will then induce anaesthesia, first preoxygenating the patient, then
administering anticholinergic agent to reduce oral secretions, anaesthesic medication, muscle
relaxation medication, and any cardiovascular prophylaxis as needed.
Once the patient is sufficiently sedated, a brief (0.5 to 2.0 milliseconds) electrical pulse will
be introduced at a level determined to reliably cause a seizure. A therapeutic ECT seizure
should last at least 15 seconds but no more than 180 seconds. Dana will be monitored for
thirty to sixty minutes once this has finished, to ensure her recovery. The goal is for further
treatments to reduce her symptoms and enable her to eat, drink, communicate, and move
again. Of course, there are adverse effects that must be considered. Anaesthesia can cause
nausea, aspiration pneumonia, dental and tongue injuries. The seizure itself can cause
cardiovascular issues, and fractures in patients with osteoporosis, and can temporarily impair
cognition and memory. It is advised that patients do not make any major or financial
decisions during or after ECT treatment, and patients must refrain from driving until a few
weeks after the last session.
For most patients, one treatment may be all that is needed. For some, continuation
of ECT as a single session every couple of weeks may help to prevent relapse.
Maintenance treatment for patients with chronically recurring psychiatric illness
may also be appropriate. The scheduling of these sessions generally depends on
the patient’s needs and episodes, sometimes even going on indefinitely. In Dana’s
case, a few treatments are all that is needed to resolve her catatonia and soon she
will be healthy enough to be discharged home with outpatient follow-up for her
mental health management.
Page 78
15. In the first paragraph, the writer mentions the role of 20th century
literature in
(A) informing patients of the side effects of antipsychotic
medication.
(B) preventing the mistreatment of defenceless people.
(C) increasing the number of patients receiving ECT.
(D) promoting a negative image of ECT.
16. What do we learn about schizophrenia in the second paragraph?
(A) It was less prevalent in patients who experienced seizures.

(B) It had a significant impact on the treatment of epilepsy.
(C) Many asylums in the UK were not prepared to treat it.
(D) The medication metrazol could be used to induce it.
17. What did the US National Institute of Mental Health decide in the 20th
century?
(A) Practitioners must follow identical treatment plans when using
ECT.
(B) Patients should be given the right to refuse ECT treatment.
(C) ECT should only be used as a treatment in severe cases.
(D) ECT was accepted as a safe treatment for patients.
18. In the fourth paragraph, what idea does the writer emphasise with the
phrase ‘it goes without saying’?
(A) Some women find ECT treatments successful while carrying a
child.
(B) It is well known that some patients will not respond well to
ECT.
(C) Few patients realise that they could benefit from ECT therapy.
(D) The risks associated with ECT are rarely discussed.
Page 79
19. In the case study, the psychiatrist decides to use ECT on Dana
(A) despite Dana’s parents’ concerns about this type of procedure.

(B) because the patient expresses a preference for this treatment.
(C) after treatment with benzodiazepines proves ineffective.
(D) as she has developed an electrolyte imbalance.
20. In the sixth paragraph, why isn’t Dana given food before her ECT
treatment?
(A) to lower the likelihood of anaesthesia-related aspiration

(B) to reduce the likelihood of vomiting during treatment
(C) as medication can interfere with the treatment
(D) as the catatonic state makes eating difficult
21. In the seventh paragraph, what does the word ‘this’ refer to?
(A) a treatment plan

(B) a seizure caused by ECT
(C) an abnormal reaction to medication
(D) an improvement to the patient’s condition
22. In the final paragraph, the writer suggests that Dana’s treatment
(A) was complete after only one ECT session.

(B) will ultimately cure her catatonia using only ECT sessions.
(C) will continue for a number of weeks before improvement can
be seen.
(D) will consist of two ECT sessions each week for the foreseeable
future.
Page 80
Kaplan Reading Answers
Practice Test
--------------------------------------------------------
Part A
1. C
2. B
3. A
4. D
5. A
6. B
-----------------------------------------------------------------------------------
7. arterial saturation
8. magnesium sulfate
9. allergies
10. life-threatening
11. reversibility testing
12. smoking
-----------------------------------------------------------------------------------
13. daily
14. every hour
15. in severe cases
16. children
17. warn ICU
18. peak expiratory flow rate OR PEFR
19. a whistling sound
20. a peak flow meter
Page 81
Part b
1. B might not need to continue with certain medication.

2. C to more accurately control how long it will last.
3. C when to prescribe antibiotics.
4. A the disorder is more difficult to identify in patients with ADHD.
5. A challenging a patient’s criticisms.
6. B staff changes are kept to a minimum.
Part c
7. B is interpreted in various ways by different people.

8. D was caused by a number of issues including money worries.
9. C many healthcare professionals do not discuss the stress they experience.
10. A to suggest that doctors are more likely to make significant errors when stressed
11. A technology that was out of date and faulty.
12. C doctors might skip over the relevant information
13. D it does not support their existing theory.
14. B a variety of possible causes
-----------------------------------------------------------------------------------
15. D promoting a negative image of ECT.
16. A It was less prevalent in patients who experienced seizures.
17. D ECT was accepted as a safe treatment for patients.
18. B It is well known that some patients will not respond well to ECT.
19. C after treatment with benzodiazepines proves ineffective.
20. A to lower the likelihood of anaesthesia-related aspiration
21. B a seizure caused by ECT
22. C will continue for a number of weeks before improvement can be seen.
Page 82
3
Sample Test 1
Page 83
Fractures, dislocations and sprains: Texts
Text A
Fractures (buckle or break in the bone) often occur following direct or indirect injury, e.g. twisting, violence
to bones. Clinically, fractures are either:
• closed, where the skin is intact, or

• compound, where there is a break in the overlying skin

Dislocation is where a bone is completely displaced from the joint. It often results from injuries away from
the affected joint, e.g. elbow dislocation after falling on an outstretched hand.
Sprain is a partial disruption of a ligament or capsule of a joint.
Text B
E
Simple Fracture of Limbs
L
Immediate management:
• Halt any external haemorrhage by pressure bandage or direct pressure

P
• Immobilise the affected area

• Provide pain relief

Clinical assessment:
• Obtain complete patient history, including circumstances and method of injury
M

- medication history – enquire about anticoagulant use, e.g. warfarin

• Perform standard clinical observations. Examine and record:
A

- colour, warmth, movement, and sensation in hands and feet of injured limb(s)

• Perform physical examination

Examine:
S

- all places where it is painful

- any wounds or swelling

- colour of the whole limb (especially paleness or blue colour)

- the skin over the fracture

- range of movement

- joint function above and below the injury site

Check whether:

- the limb is out of shape – compare one side with the other

- the limb is warm

- the limb (if swollen) is throbbing or getting bigger

- peripheral pulses are palpable

Management:
• Splint the site of the fracture/dislocation using a plaster backslab to reduce pain

• Elevate the limb – a sling for arm injuries, a pillow for leg injuries

• If in doubt over an injury, treat as a fracture

• Administer analgesia to patients in severe pain. If not allergic, give morphine (preferable); if allergic

to morphine, use fentanyl

• Consider compartment syndrome where pain is severe and unrelieved by splinting and elevation or

two doses of analgesia

• X-ray if available

SAMPLE
[CANDIDATE NO.] READING TEXT BOOKLET PART A 02/04 Page 84

Text C
Drug Therapy Protocol:

Authorised Indigenous Health Worker (IHW) must consult Medical Officer (MO) or Nurse Practitioner (NP).
Scheduled Medicines Rural & Isolated Practice Registered Nurse may proceed.
Drug Form Strength Route of Recommended dosage Duration

administration
Adult only:
IM/SC 0.1-0.2 mg/kg to a max. of
10 mg Stat
E
Further
Morphine Ampoule 10 mg/mL Adult only: doses on
IV Initial dose of 2 mg then MO/NP
L
(IHW may not 0.5-1 mg increments slowly, order
administer IV) repeated every 3-5
P
minutes if required to a
max. of 10 mg
Use the lower end of dose range in patients ≥70 years.
M
Provide Consumer Medicine Information: advise can cause nausea and vomiting, drowsiness.
Respiratory depression is rare – if it should occur, give naloxone.
A
Text D
S
Technique for plaster backslab for arm fractures – use same principle for leg fractures
1. Measure a length of non-compression cotton stockinette from half way up the middle finger to just
below the elbow. Width should be 2–3 cm more than the width of the distal forearm.

2. Wrap cotton padding over top for the full length of the stockinette — 2 layers, 50% overlap.

3. Measure a length of plaster of Paris 1 cm shorter than the padding/stockinette at each end. Fold the

roll in about ten layers to the same length.

4. Immerse the layered plaster in a bowl of room temperature water, holding on to each end. Gently

squeeze out the excess water.

5. Ensure any jewellery is removed from the injured limb.
6. Lightly mould the slab to the contours of the arm and hand in a neutral position.

7. Do not apply pressure over bony prominences. Extra padding can be placed over bony prominences if

applicable.

8. Wrap crepe bandage firmly around plaster backslab.
END OF PART A
THIS TEXT BOOKLET WILL BE COLLECTED
SAMPLE

Part A
TIME: 15 minutes
• Look at the four texts, A-D, in the separate Text Booklet.
• For each question, 1-20, look through the texts, A-D, to find the relevant information.
• Write your answers on the spaces provided in this Question Paper.
• Answer all the questions within the 15-minute time limit.
• Your answers should be correctly spelt.
L E
Fractures, dislocations and sprains: Questions
Questions 1-7
P

For each question, 1-7, decide which text (A, B, C or D) the information comes from. You may use any

letter more than once.
M

A
1 procedures for delivering pain relief?

2 the procedure to follow when splinting a fractured limb?
S

3 what to record when assessing a patient?

4 the terms used to describe different types of fractures?

5 the practitioners who administer analgesia?

6 what to look for when checking an injury?

7 how fractures can be caused?

Questions 8-14

Answer each of the questions, 8-14, with a word or short phrase from one of the texts. Each answer may include
words, numbers or both.
8 What should be used to elevate a patient’s fractured leg?

9 What is the maximum dose of morphine per kilo of a patient’s weight that can be given using

the intra-muscular (IM) route?

10 Which parts of a limb may need extra padding?
SAMPLE

[CANDIDATE NO.] READING QUESTION PAPER PART A 02/04 Page 86
11 What should be used to treat a patient who suffers respiratory depression?

12 What should be used to cover a freshly applied plaster backslab?

13 What analgesic should be given to a patient who is allergic to morphine?

E
14 What condition might a patient have if severe pain persists after splinting, elevation and

L
repeated analgesia?

P

Questions 15-20

M
Complete each of the sentences, 15-20, with a word or short phrase from one of the texts. Each answer may
include words, numbers or both.
A
15 Falling on an outstretched hand is a typical cause of a of

the elbow.
S

16 Upper limb fractures should be elevated by means of a .

17 Make sure the patient isn’t wearing any on the part of the

body where the plaster backslab is going to be placed.

18 Check to see whether swollen limbs are or increasing

in size.

19 In a plaster backslab, there is a layer of closest to the skin.

20 Patients aged and over shouldn’t be given the higher

dosages of pain relief.

END OF PART A

THIS QUESTION PAPER WILL BE COLLECTED
SAMPLE

Part B
In this part of the test, there are six short extracts relating to the work of health professionals. For questions 1-6,
choose the answer (A, B or C) which you think fits best according to the text.

1. The manual informs us that the Blood Pressure Monitor
A is likely to interfere with the operation of other medical equipment.
E
B may not work correctly in close proximity to some other devices.
C should be considered safe to use in all hospital environments.
P
Instruction Manual: Digital Automatic Blood Pressure Monitor
L
M
Electromagnetic Compatibility (EMC)
With the increased use of portable electronic devices, medical equipment may be susceptible to
A
electromagnetic interference. This may result in incorrect operation of the medical device and create a
potentially unsafe situation. In order to regulate the requirements for EMC, with the aim of preventing
S
unsafe product situations, the EN60601-1-2 standard defines the levels of immunity to electromagnetic
interferences as well as maximum levels of electromagnetic emissions for medical devices. This medical
device conforms to EN60601-1-2:2001 for both immunity and emissions. Nevertheless, care should be
taken to avoid the use of the monitor within 7 metres of cellphones or other devices generating strong
electrical or electromagnetic fields.
SAMPLE
[CANDIDATE NO.] READING QUESTION PAPER PARTS B & C 02/16 Page 88

2. The notice is giving information about
A ways of checking that an NG tube has been placed correctly.
B how the use of NG feeding tubes is authorised.
C which staff should perform NG tube placement.
E
NG feeding tubes
Displacement of nasogastric (NG) feeding tubes can have serious implications if undetected. Incorrectly
L
positioned tubes leave patients vulnerable to the risks of regurgitation and respiratory aspiration. It is crucial to
differentiate between gastric and respiratory placement on initial insertion to prevent potentially fatal pulmonary
P
complications. Insertion and care of an NG tube should therefore only be carried out by a registered doctor or
nurse who has undergone theoretical and practical training and is deemed competent or is supervised by someone
M
competent. Assistant practitioners and other unregistered staff must never insert NG tubes or be involved in the
initial confirmation of safe NG tube position.
S A
SAMPLE

3. What must all staff involved in the transfusion process do?
A check that their existing training is still valid
B attend a course to learn about new procedures
C read a document that explains changes in policy
E
'Right Patient, Right Blood' Assessments
The administration of blood can have significant morbidity and mortality. Following the introduction of the
L
'Right Patient, Right Blood' safety policy, all staff involved in the transfusion process must be competency
assessed. To ensure the safe administration of blood components to the intended patient, all staff must be
P
aware of their responsibilities in line with professional standards.
Staff must ensure that if they take any part in the transfusion process, their competency assessment is
M
updated every three years. All staff are responsible for ensuring that they attend the mandatory training
identified for their roles. Relevant training courses are clearly identified in Appendix 1 of the Mandatory
A
Training Matrix.
SAMPLE

4. The guidelines establish that the healthcare professional should
A aim to make patients fully aware of their right to a chaperone.
B evaluate the need for a chaperone on a case-by-case basis.
C respect the wishes of the patient above all else.
E
Extract from ‘Chaperones: Guidelines for Good Practice’
A patient may specifically request a chaperone or in certain circumstances may nominate one, but it will
L
not always be the case that a chaperone is required. It is often a question of using professional judgement
to assess an individual situation. If a chaperone is offered and declined, this must be clearly documented
P
in the patient’s record, along with any relevant discussion. The chaperone should only be present for the
physical examination and should be in a position to see what the healthcare professional undertaking
M
the examination/investigation is doing. The healthcare professional should wait until the chaperone has
left the room/cubicle before discussion takes place on any aspect of the patient’s care, unless the patient
A
specifically requests the chaperone to remain.
SAMPLE

5. The guidelines require those undertaking a clinical medication review to
A involve the patient in their decisions.
B consider the cost of any change in treatments.
C recommend other services as an alternative to medication.
E
Annual medication review
L
To give all patients an annual medication review is an ideal to strive for. In the meantime there is an
argument for targeting all clinical medication reviews to those patients likely to benefit most.
P
Our guidelines state that ‘at least a level 2 medication review will occur’, i.e. the minimum standard is a
treatment review of medicines with the full notes but not necessarily with the patient present. However,
the guidelines go on to say that ‘all patients should have the chance to raise questions and highlight
M
problems about their medicines’ and that ‘any changes resulting from the review are agreed with the
patient’.
A
It also states that GP practices are expected to
S
• minimise waste in prescribing and avoid ineffective treatments.

• engage effectively in the prevention of ill health.

• avoid the need for costly treatments by proactively managing patients to recovery through

the whole care pathway.

SAMPLE

6. The purpose of this email is to
A report on a rise in post-surgical complications.
B explain the background to a change in patient care.
C remind staff about procedures for administrating drugs.
E
To: All staff
L
Subject: Advisory Email: Safe use of opioids
In August, an alert was issued on the safe use of opioids in hospitals. This reported the incidence
P
of respiratory depression among post-surgical patients to an average 0.5% – thus for every 5,000
surgical patients, 25 will experience respiratory depression. Failure to recognise respiratory depression
M
and institute timely intervention can lead to cardiopulmonary arrest, resulting in brain injury or
death. A retrospective multi-centre study of 14,720 cardiopulmonary arrest cases showed that
A
44% were respiratory related and more than 35% occurred on the general care floor. It is therefore
S
recommended that post-operative patients now have continuous monitoring, instead of spot checks, of
both oxygenation and ventilation.
SAMPLE

Part C
In this part of the test, there are two texts about different aspects of healthcare. For questions 7-22, choose the
answer (A, B, C or D) which you think fits best according to the text.
Text 1: Sleep deprivation
Millions of people who suffer sleep problems also suffer myriad health burdens. In addition to emotional distress
and cognitive impairments, these can include high blood pressure, obesity, and metabolic syndrome. ‘In the studies
E
we’ve done, almost every variable we measured was affected. There’s not a system in the body that’s not affected
by sleep,’ says University of Chicago sleep researcher Eve Van Cauter. ‘Every time we sleep-deprive ourselves,
L
things go wrong.’
P
A common refrain among sleep scientists about two decades ago was that sleep was performed by the brain in the
interest of the brain. That wasn’t a fully elaborated theory, but it wasn’t wrong. Numerous recent studies have hinted
at the purpose of sleep by confirming that neurological function and cognition are messed up during sleep loss, with
M
the patient’s reaction time, mood, and judgement all suffering if they are kept awake too long.
A
In 1997, Bob McCarley and colleagues at Harvard Medical School found that when they kept cats awake by playing
with them, a compound known as adenosine increased in the basal forebrain as the sleepy felines stayed up
S
longer, and slowly returned to normal levels when they were later allowed to sleep. McCarley’s team also found
that administering adenosine to the basal forebrain acted as a sedative, putting animals to sleep. It should come as
no surprise then that caffeine, which blocks adenosine’s receptor, keeps us awake. Teaming up with Basheer and
others, McCarley later discovered that, as adenosine levels rise during sleep deprivation, so do concentrations of
adenosine receptors, magnifying the molecule’s sleep-inducing effect. ‘The brain has cleverly designed a two-stage
defence against the consequences of sleep loss,’ McCarley says. Adenosine may underlie some of the cognitive
deficits that result from sleep loss. McCarley and colleagues found that infusing adenosine into rats’ basal forebrain
impaired their performance on an attention test, similar to that seen in sleep-deprived humans. But adenosine
levels are by no means the be-all and end-all of sleep deprivation’s effects on the brain or the body.
Over a century of sleep research has revealed numerous undesirable outcomes from staying awake too long. In
1999, Van Cauter and colleagues had eleven men sleep in the university lab. For three nights, they spent eight
hours in bed, then for six nights they were allowed only four hours (accruing what Van Cauter calls a sleep debt),
and then for six nights they could sleep for up to twelve hours (sleep recovery). During sleep debt and recovery,
researchers gave the participants a glucose tolerance test and found striking differences. While sleep deprived, the
men’s glucose metabolism resembled a pre-diabetic state. ‘We knew it would be affected,’ says Van Cauter. ‘The
big surprise was the effect being much greater than we thought.’
SAMPLE

Subsequent studies also found insulin resistance increased during bouts of sleep restriction, and in 2012, Van
Cauter’s team observed impairments in insulin signalling in subjects’ fat cells. Another recent study showed
that sleep-restricted people will add 300 calories to their daily diet. Echoing Van Cauter’s results, Basheer has
found evidence that enforced lack of sleep sends the brain into a catabolic, or energy-consuming, state. This is
because it degrades the energy molecule adenosine triphosphate (ATP) to produce adenosine monophosphate
and this results in the activation of AMP kinase, an enzyme that boosts fatty acid synthesis and glucose utilization.
‘The system sends a message that there’s a need for more energy,’ Basheer says. Whether this is indeed the
mechanism underlying late-night binge-eating is still speculative.
E
Within the brain, scientists have glimpsed signs of physical damage from sleep loss, and the time-line for recovery,
L
if any occurs, is unknown. Chiara Cirelli’s team at the Madison School of Medicine in the USA found structural
changes in the cortical neurons of mice when the animals are kept awake for long periods. Specifically, Cirelli and
P
colleagues saw signs of mitochondrial activation – which makes sense, as ‘neurons need more energy to stay
awake,’ she says – as well as unexpected changes, such as undigested cellular debris, signs of cellular aging that
are unusual in the neurons of young, healthy mice. ‘The number [of debris granules] was small, but it’s worrisome
M
because it’s only four to five days’ of sleep deprivation,’ says Cirelli. After thirty-six hours of sleep recovery, a period
during which she expected normalcy to resume, those changes remained.
A
Further insights could be drawn from the study of shift workers and insomniacs, who serve as natural experiments
S
on how the human body reacts to losing out on such a basic life need for chronic periods. But with so much of
our physiology affected, an effective therapy − other than sleep itself – is hard to imagine. ‘People like to define a
clear pathway of action for health conditions,’ says Van Cauter. ‘With sleep deprivation, everything you measure is
affected and interacts synergistically to produce the effect.’
SAMPLE

Text 1: Questions 7-14
7. In the first paragraph, the writer uses Eve Van Cauter’s words to
A explain the main causes of sleep deprivation.
B reinforce a view about the impact of sleep deprivation.
C question some research findings about sleep deprivation.
D describe the challenges involved in sleep deprivation research.
E
8. What do we learn about sleep in the second paragraph?

L
A Scientific opinion about its function has changed in recent years.
P
B There is now more controversy about it than there was in the past.
C Researchers have tended to confirm earlier ideas about its purpose.
M
D Studies undertaken in the past have formed the basis of current research.
A
9. What particularly impressed Bob McCarley of Harvard Medical School?
S
A the effectiveness of adenosine as a sedative
B the influence of caffeine on adenosine receptors
C the simultaneous production of adenosine and adenosine receptors
D the extent to which adenosine levels fall when subjects are allowed to sleep
10. In the third paragraph, what idea is emphasised by the phrase ‘by no means the be-all and end-all’?
A Sleep deprivation has consequences beyond its impact on adenosine levels.
B Adenosine levels are a significant factor in situations other than sleep deprivation.
C The role of adenosine as a response to sleep deprivation is not yet fully understood.
D The importance of the link between sleep deprivation and adenosine should not be underestimated.
SAMPLE

11. What was significant about the findings in Van Cauter’s experiment?
A the rate at which the sleep-deprived men entered a pre-diabetic state
B the fact that sleep deprivation had an influence on the men’s glucose levels
C the differences between individual men with regard to their glucose tolerance
D the extent of the contrast in the men’s metabolic states between sleep debt and recovery
E
12. In the fifth paragraph, what does the word ‘it’ refer to?
L
A an enzyme
P
B new evidence
C a catabolic state
M
D enforced lack of sleep
A
13. What aspect of her findings surprised Chiara Cirelli?
S
A There was no reversal of a certain effect of sleep deprivation.
B The cortical neurons of the mice underwent structural changes.
C There was evidence of an increased need for energy in the brains of the mice.
D The neurological response to sleep deprivation only took a few hours to become apparent.
14. In the final paragraph, the quote from Van Cauter is used to suggest that
A the goals of sleep deprivation research are sometimes unclear.
B it could be difficult to develop any treatment for sleep deprivation.
C opinions about the best way to deal with sleep deprivation are divided.
D there is still a great deal to be learnt about the effects of sleep deprivation.
SAMPLE

Text 2: ADHD
The American Psychiatric Association (APA) recognised Attention Deficit Hyperactivity Disorder (ADHD) as a
childhood disorder in the 1960s, but it wasn’t until 1978 that the condition was formally recognised as afflicting
adults. In recent years, the USA has seen a 40% rise in diagnoses of ADHD in children. It could be that the disorder
is becoming more prevalent, or, as seems more plausible, doctors are making the diagnosis more frequently. The
issue is complicated by the lack of any recognised neurological markers for ADHD. The APA relies instead on a
set of behavioural patterns for diagnosis. It specifies that patients under 17 must display at least six symptoms of
inattention and/or hyperactivity; adults need only display five.
L E
ADHD can be a controversial condition. Dr Russell Barkley, Professor of Psychiatry at the University of
Massachusetts insists; ‘the science is overwhelming: it’s a real disorder, which can be managed, in many cases, by
P
using stimulant medication in combination with other treatments’. Dr Richard Saul, a behavioural neurologist with
five decades of experience, disagrees; ‘Many of us have difficulty with organization or details, a tendency to lose
things, or to be forgetful or distracted. Under such subjective criteria, the entire population could potentially qualify.
M
Although some patients might need stimulants to function well in daily life, the lumping together of many vague and
subjective symptoms could be causing a national phenomenon of misdiagnosis and over-prescription of stimulants.’
A
A recent study found children in foster care three times more likely than others to be diagnosed with ADHD.
S
Researchers also found that children with ADHD in foster care were more likely to have another disorder, such
as depression or anxiety. This finding certainly reveals the need for medical and behavioural services for these
children, but it could also prove the non-specific nature of the symptoms of ADHD: anxiety and depression, or an
altered state, can easily be mistaken for manifestations of ADHD.
ADHD, the thinking goes, begins in childhood. In fact, in order to be diagnosed with it as an adult, a patient must
demonstrate that they had traits of the condition in childhood. However, studies from the UK and Brazil, published
in JAMA Psychiatry, are fuelling questions about the origins and trajectory of ADHD, suggesting not only that it
can begin in adulthood, but that there may be two distinct syndromes: adult-onset ADHD and childhood ADHD.
They echo earlier research from New Zealand. However, an editorial by Dr Stephen Faraone in JAMA Psychiatry
highlights potential flaws in the findings. Among them, underestimating the persistence of ADHD into adulthood
and overestimating the prevalence of adult-onset ADHD. In Dr Faraone’s words, ‘the researchers found a group
of people who had sub-threshold ADHD in their youth. There may have been signs that things weren’t right, but
not enough to go to a doctor. Perhaps these were smart kids with particularly supportive parents or teachers who
helped them cope with attention problems. Such intellectual and social scaffolding would help in early life, but when
the scaffolding is removed, full ADHD could develop’.
SAMPLE

Until this century, adult ADHD was a seldom-diagnosed disorder. Nowadays however, it’s common in mainstream
medicine in the USA, a paradigm shift apparently driven by two factors: reworked – many say less stringent –
diagnostic criteria, introduced by the APA in 2013, and marketing by manufacturers of ADHD medications. Some
have suggested that this new, broader definition of ADHD was fuelled, at least in part, to broaden the market for
medication. In many instances, the evidence proffered to expand the definitions came from studies funded in whole
or part by manufacturers. And as the criteria for the condition loosened, reports emerged about clinicians involved
in diagnosing ADHD receiving money from drug-makers.
This brings us to the issue of the addictive nature of ADHD medication. As Dr Saul asserts, ‘addiction to stimulant
E
medication isn’t rare; it’s common. Just observe the many patients periodically seeking an increased dosage
L
as their powers of concentration diminish. This is because the body stops producing the appropriate levels of
neurotransmitters that ADHD drugs replace − a trademark of addictive substances.’ Much has been written about
P
the staggering increase in opioid overdoses and abuse of prescription painkillers in the USA, but the abuse of
drugs used to treat ADHD is no less a threat. While opioids are more lethal than prescription stimulants, there are
parallels between the opioid epidemic and the increase in problems tied to stimulants. In the former, users switch
M
from prescription narcotics to heroin and illicit fentanyl. With ADHD drugs, patients are switching from legally
prescribed stimulants to illicit ones such as methamphetamine and cocaine. The medication is particularly prone to
A
abuse because people feel it improves their lives. These drugs are antidepressants, aid weight-loss and improve
confidence, and can be abused by students seeking to improve their focus or academic performance. So, more
S
work needs to be done before we can settle the questions surrounding the diagnosis and treatment of ADHD.
SAMPLE

15. In the first paragraph, the writer questions whether
A adult ADHD should have been recognised as a disorder at an earlier date.
B ADHD should be diagnosed in the same way for children and adults.
C ADHD can actually be indicated by neurological markers.
D cases of ADHD have genuinely increased in the USA.
E
16. What does Dr Saul object to?
L
A the suggestion that people need stimulants to cope with everyday life
P
B the implication that everyone has some symptoms of ADHD
C the grouping of imprecise symptoms into a mental disorder
M
D the treatment for ADHD suggested by Dr Barkley
A
17. The writer regards the study of children in foster care as significant because it
S
A highlights the difficulty of distinguishing ADHD from other conditions.
B focuses on children known to have complex mental disorders.
C suggests a link between ADHD and a child’s upbringing.
D draws attention to the poor care given to such children.
18. In the fourth paragraph, the word ‘They’ refers to

A syndromes.
B questions.
C studies.
D origins.
SAMPLE
19. Dr Faraone suggests that the group of patients diagnosed with adult-onset ADHD

A had teachers or parents who recognised the symptoms of ADHD.
B should have consulted a doctor at a younger age.
C had mild undiagnosed ADHD in childhood.
D were specially chosen by the researchers.
E
20. In the fifth paragraph, it is suggested that drug companies have
L
A been overly aggressive in their marketing of ADHD medication.
P
B influenced research that led to the reworking of ADHD diagnostic criteria.
C attempted to change the rules about incentives for doctors who diagnose ADHD.
M
D encouraged the APA to rush through changes to the criteria for diagnosing ADHD.
A
21. In the final paragraph, the word ‘trademark’ refers to
S
A a physiological reaction.
B a substitute medication.
C a need for research.
D a common request.
22. In the final paragraph, what does the writer imply about addiction to ADHD medication?
A It is unlikely to turn into a problem on the scale of that caused by opioid abuse.
B The effects are more marked in certain sectors of the population.
C Insufficient attention seems to have been paid to it.
D The reasons for it are not yet fully understood.
END OF READING TEST

THIS BOOKLET WILL BE COLLECTED
SAMPLE
Sample Test 1
READING SUB-TEST – ANSWER KEY

PART A
PART A: QUESTIONS 1-20
E
1 C
L
2 D
3 B
P
4 A
5 C
6 B
M
7 A
8 (a) pillow / pillows
A
9 0.2 mg (/kg)
10 bony prominences
S
11 naloxone
12 crêpe/crepe bandage
13 fentanyl
14 compartment syndrome
15 dislocation
16 sling
17 jewellery
18 throbbing
19 (cotton / non-compression) stockinette
20 70 / seventy (years / yrs)
www.occupationalenglishtest.org
© Cambridge Boxhill Language Assessment – ABN 51 988 559 414 Page 102

Sample Test 1

PARTS B & C
READING SUB-TEST - ANSWER KEY
E
PART B: QUESTIONS 1-6
L
1 B may not work correctly in close proximity to some other devices.
2 C which staff should perform NG tube placement.
P
3 A check that their existing training is still valid
4 B evaluate the need for a chaperone on a case-by-case basis.
M
5 A involve the patient in their decisions.
6 B explain the background to a change in patient care.
A
PART C: QUESTIONS 7-14
S
7 B reinforce a view about the impact of sleep deprivation.
8 C Researchers have tended to confirm earlier ideas about its purpose.
9 C the simultaneous production of adenosine and adenosine receptors
10 A Sleep deprivation has consequences beyond its impact on adenosine levels.
11 D the extent of the contrast in the men’s metabolic states between sleep debt and recovery
12 D enforced lack of sleep
13 A There was no reversal of a certain effect of sleep deprivation.
14 B it could be difficult to develop any treatment for sleep deprivation.
15 D cases of ADHD have genuinely increased in the USA.

16 C the grouping of imprecise symptoms into a mental disorder
17 A highlights the difficulty of distinguishing ADHD from other conditions.
18 C studies.
19 C had mild undiagnosed ADHD in childhood.
20 B influenced research that led to the reworking of ADHD diagnostic criteria.
21 A a physiological reaction.
22 C Insufficient attention seems to have been paid to it.

4
Sample Test 2
Page 104
6. Extract from Appropriate Treatment for Pain
Pain is one of the most common complaints that will be brought

to a physician’s attention. This section will cover treatment of
mild to moderate pain without the use of opioids. More severe
pain may require judicious use of short-acting opioid
medications or a consult to pain medicine. For most patients, the
first line medications for pain are acetaminophen and ibuprofen.
Maximum daily dosage of acetaminophen is suggested to be 4
grams, reduced to under 2 grams for patients with liver issues
such as a cirrhosis. Ibuprofen is particularly effective in patients
whose pain is caused by inflammation, though caution is urged
in elderly patients, patients with diagnosed bleeding issues
(especially gastrointestinal bleeds), or any cardiac issues.
Maximum daily dosage suggested is 2.4 grams. A combination
of acetaminophen and ibuprofen can be used if either one used
alone is not sufficient. For more localised pain relief, consider
using lidocaine dermal patches over non-broken areas of skin.
The guidelines advise that patients with heart problems
(A) may need to avoid ibuprofen.

(B) should be given lidocaine for pain relief.
(C) must receive a lower dose of acetaminophen.
Page 36
Text C
Paracetamol poisoning – Emergency treatment of poisoning
Patients whose plasma-paracetamol
200
200 concentrations are above the normal
1.3
190 1.3 treatment line should be treated with
190
180
1.2
1.2 acetylcysteine by intravenous infusion
180
170 (or, if acetylcysteine cannot be used,
170 1.1
160 1.1 with methionine by mouth, provided the
Plasma-paracetamol concentration (mmol/litre)

160
Plasma-paracetamol concentration (mg/litre)
Plasma-paracetamol concentration (mmol/litre)

overdose has been taken within 10-12
Plasma-paracetamol concentration (mg/litre)
150 1
150 Normal treatment line 1
140 Normal treatment line hours and the patient is not vomiting).
140 0.9
130 0.9
130
120 0.8 Patients on enzyme-inducing drugs
120 0.8
110 (e.g. carbamazepine, phenobarbital,
110 0.7
100 0.7 phenytoin, primidone, rifampicin and St
100
90 0.6 John’s wort) or who are malnourished
90 0.6
80
(e.g. in anorexia, in alcoholism, or those
80
70 0.5
0.5 who are HIV positive) should be treated
70
with acetylcysteine if their plasma-
60 0.4
60 0.4 paracetamol concentration is above the
50
50
0.3
0.3 high-risk treatment line.
40
40
30 0.2
30 0.2
20
20 High-risk treatment line 0.1
10 High-risk treatment line 0.1
10
0 0
0 0
0 2 4 6 8 10 12 14 16 18 20 22 24
0 2 4 6 8 10 Time
12 14(hours)
16 18 20 22 24
Text D
Clinical Assessment
• Commonly, patients who have taken a paracetamol overdose are asymptomatic for the first 24 hours or just have
nausea and vomiting
• Hepatic necrosis (elevated transaminases, right upper quadrant pain and jaundice) begins to develop after 24
hours and can progress to acute liver failure (ALF)
• Patients may also develop:
• Encephalopathy • Renal failure – usually occurs around day three
• Oliguria • Lactic acidosis
• Hypoglycaemia
History
• Number of tablets, formulation, any concomitant tablets
• Time of overdose
• Suicide risk – was a note left?
• Any alcohol taken (acute alcohol ingestion will inhibit liver enzymes and may reduce the production of the toxin
NAPQI, whereas chronic alcoholism may increase it)
END OF PART A
SAMPLE

Sample Test 2
READING SUB-TEST – QUESTION PAPER: PART A
CANDIDATE NUMBER:
LAST NAME:
FIRST NAME:
E
Passport Photo
OTHER NAMES: Your details and photo will be printed here.
L
PROFESSION:
VENUE:
P
TEST DATE:
CANDIDATE SIGNATURE:
M

A
TIME: 15 MINUTES
S
INSTRUCTIONS TO CANDIDATES:
DO NOT open this Question Paper or the Text Booklet until you are told to do so.
Write your answers on the spaces provided on this Question Paper.
You must answer the questions within the 15-minute time limit.
One mark will be granted for each correct answer.
Answer ALL questions. Marks are NOT deducted for incorrect answers.
At the end of the 15 minutes, hand in this Question Paper and the Text Booklet.
DO NOT remove OET material from the test room.
SAMPLE
© Cambridge Boxhill Language Assessment – ABN 51 988 559 414

Part A
TIME: 15 minutes
E
Paracetamol overdose: Questions
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Questions 1-7

P

M

1 the various symptoms of patients who have taken too much paracetamol?
A

2 the precise levels of paracetamol in the blood which require urgent intervention?

S
3 the steps to be taken when treating a paracetamol overdose patient?

4 whether paracetamol overdose was intentional?

5 the number of products containing paracetamol?

6 what to do if there are no details available about the time of the overdose?

7 dealing with paracetamol overdose patients who have not received adequate nutrition?

Questions 8-13

Answer each of the questions, 8-13, with a word or short phrase from one of the texts. Each answer may
8 If paracetamol is used as a long-term painkiller, what symptom may get worse?

9 It may be dangerous to administer paracetamol to a patient with which viral condition?

10 What condition may develop in an overdose patient who presents with jaundice?

SAMPLE

11 What condition may develop on the third day after an overdose?

12 What drug can be administered orally within 10 - 12 hours as an alternative to acetylcysteine?

13 What treatment can be used if a single overdose has occurred less than an hour ago?

E
Questions 14-20

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P
14 If a patient has taken metoclopramide alongside paracetamol, this may affect the

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of the paracetamol.

A
15 After 24 hours, an overdose patient may present with pain in the .

S
16 For the first 24 hours after overdosing, patients may only have such symptoms as

.

17 Acetylcysteine should be administered to patients with a paracetamol level above the high-risk treatment

line who are taking any type of medication.

18 A non-high-risk patient should be treated for paracetamol poisoning if their paracetamol level is above

mg/litre 8 hours after overdosing.

19 A high-risk patient who overdosed hours ago should be given

acetylcysteine if their paracetamol level is 25 mg/litre or higher.

20 If a patient does not require further acetylcysteine, they should be given treatment categorised as

only.

END OF PART A

SAMPLE

Sample Test 2
READING SUB-TEST – QUESTION PAPER: PARTS B & C
CANDIDATE NUMBER:
LAST NAME:
FIRST NAME:
E
Passport Photo
OTHER NAMES: Your details and photo will be printed here.
L
PROFESSION:
VENUE:
P
TEST DATE:
CANDIDATE SIGNATURE:
M

A
TIME: 45 MINUTES
INSTRUCTIONS TO CANDIDATES:
S
DO NOT open this Question Paper until you are told to do so.
One mark will be granted for each correct answer.
Answer ALL questions. Marks are NOT deducted for incorrect answers.
At the end of the test, hand in this Question Paper.
DO NOT remove OET material from the test room.
HOW TO ANSWER THE QUESTIONS:

Mark your answers on this Question Paper by filling in the circle using a 2B pencil.

Example:

A

B

C

SAMPLE
© Cambridge Boxhill Language Assessment – ABN 51 988 559 414
Page 110

[CANDIDATE NO.] READING QUESTION PAPER PARTS B & C 01/16
Part B
choose the answer (A, B or C) which you think fits best according to the text.

1. This guideline extract says that the nurse in charge
A must supervise the opening of the controlled drug cupboard.
E
B should make sure that all ward cupboard keys are kept together.
C can delegate responsibility for the cupboard keys to another ward.
Medicine Cupboard Keys
P L
The keys for the controlled drug cupboard are the responsibility of the nurse in charge. They may
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be passed to a registered nurse in order for them to carry out their duties and returned to the nurse
A
in charge. If the keys for the controlled drug cupboard go missing, the locks must be changed and
pharmacy informed and an incident form completed. The controlled drug cupboard keys should be kept
S
separately from the main body of keys. Apart from in exceptional circumstances, the keys should not
leave the ward or department. If necessary, the nurse in charge should arrange for the keys to be held in
a neighbouring ward or department by the nurse in charge there.
SAMPLE
2. When seeking consent for a post-mortem examination, it is necessary to
A give a valid reason for conducting it.
B allow all relatives the opportunity to decline it.
C only raise the subject after death has occurred.
E
Post-Mortem Consent
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A senior member of the clinical team, preferably the Consultant in charge of the care, should raise the
possibility of a post-mortem examination with the most appropriate person to give consent. The person
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consenting will need an explanation of the reasons for the post-mortem examination and what it hopes
to achieve. The first approach should be made as soon as it is apparent that a post-mortem examination
may be desirable, as there is no need to wait until the patient has died. Many relatives are more
M
prepared for the consenting procedure if they have had time to think about it beforehand.
S A
SAMPLE
Exercise
yourself.
5. The writer uses the phrase ‘raising the bar’ to underline the
(A) complexity of modern devices.

(B) need for a diverse range of voices.
(C) high quality of the sound recordings.
(D) number of new communication systems.
6. What is suggested about voice donation by the phrase ‘go the extra
mile’?
(A) donation centres are often far away

(B) a large number of voices are rejected
(C) donators sacrifice more than organ donators
(D) the process is extremely time-consuming
Page 41
4. What does this manual tell us about spacer devices?
A Patients should try out a number of devices with their inhaler.
B They enable a patient to receive more of the prescribed medicine.
C Children should be given spacers which are smaller than those for adults.
Manual extract: Spacer devices for asthma patients
Spacer devices remove the need for co-ordination between actuation of a pressurized metered-dose
inhaler and inhalation. In addition, the device allows more time for evaporation of the propellant so that a
larger proportion of the particles can be inhaled and deposited in the lungs. Spacer devices are particularly
useful for patients with poor inhalation technique, for children, for patients requiring higher doses, for
nocturnal asthma, and for patients prone to candidiasis with inhaled corticosteroids. The size of the spacer
is important, the larger spacers with a one-way valve being most effective. It is important to prescribe a
spacer device that is compatible with the metered-dose inhaler. Spacer devices should not be regarded as
interchangeable; patients should be advised not to switch between spacer devices.
SAMPLE
5. The email is reminding staff that the
A benefits to patients of using bedrails can outweigh the dangers.
B number of bedrail-related accidents has reached unacceptable levels.
C patient’s condition should be central to any decision about the use of bedrails.
To: All Staff
Subject: Use of bed rails
Please note the following.
Patients in hospital may be at risk of falling from bed for many reasons including

poor mobility, dementia or delirium, visual impairment, and the effects of treatment or

medication. Bedrails can be used as safety devices intended to reduce risk.

However, bedrails aren’t appropriate for all patients, and their use involves risks. National

data suggests around 1,250 patients injure themselves on bedrails annually, usually

scrapes and bruises to their lower legs. Statistics show 44,000 reports of patient falls

from bed annually resulting in 11 deaths, while deaths due to bedrail entrapment

occur less than one every two years, and are avoidable if the relevant advice is followed.

Staff should continue to take great care to avoid bedrail entrapment, but be aware that in

hospital settings there may be a greater risk of harm to patients who fall out of bed.

SAMPLE
6. What does this extract from a handbook tell us about analeptic drugs?
A They may be useful for patients who are not fully responsive.
B Injections of these drugs will limit the need for physiotherapy.
C Care should be taken if they are used over an extended period.
Analeptic drugs
Respiratory stimulants (analeptic drugs) have a limited place in the treatment of ventilatory failure in
patients with chronic obstructive pulmonary disease. They are effective only when given by intravenous
injection or infusion and have a short duration of action. Their use has largely been replaced by ventilatory
support. However, occasionally when ventilatory support is contra-indicated and in patients with
hypercapnic respiratory failure who are becoming drowsy or comatose, respiratory stimulants in the short
term may arouse patients sufficiently to co-operate and clear their secretions.
Respiratory stimulants can also be harmful in respiratory failure since they stimulate non-respiratory as
well as respiratory muscles. They should only be given under expert supervision in hospital and must be
combined with active physiotherapy. At present, there is no oral respiratory stimulant available for long-
term use in chronic respiratory failure.
SAMPLE
Part C
In this part of the test, there are two texts about different aspects of healthcare. For questions 7-22, choose

the answer (A, B, C or D) which you think fits best according to the text.
Text 1: Patient Safety

Highlighting a collaborative initiative to improve patient safety
In a well-documented case in November 2004, a female patient called Mary was admitted to a hospital in Seattle,
USA, to receive treatment for a brain aneurysm. What followed was a tragedy, made worse by the fact that it
needn’t have occurred at all. The patient was mistakenly injected with the antiseptic chlorhexidine. It happened, the
hospital says, because of ‘confusion over the three identical stainless steel bowls in the procedure room containing
clear liquids — chlorhexidine, contrast dye and saline solution’. Doctors tried amputating one of Mary’s legs to save
her life, but the damage to her organs was too great: she died 19 days later.
This and similar incidents are what inspired Professor Dixon-Woods of the University of Cambridge, UK, to set
out on a mission: to improve patient safety. It is, she admits, going to be a challenge. Many different policies and
approaches have been tried to date, but few with widespread success, and often with unintended consequences.
Financial incentives are widely used, but recent evidence suggests that they have little effect. ‘There’s a danger
that they tend to encourage effort substitution,’ explains Dixon-Woods. In other words, people concentrate on the
areas that are being incentivised, but neglect other areas. ‘It’s not even necessarily conscious neglect. People have
only a limited amount of time, so it’s inevitable they focus on areas that are measured and rewarded.’
In 2013, Dixon-Woods and colleagues published a study evaluating the use of surgical checklists introduced in
hospitals to reduce complications and deaths during surgery. Her research found that that checklists may have
little impact, and in some situations might even make things worse. ‘The checklists sometimes introduced new
risks. Nurses would use the lists as box-ticking exercises – they would tick the box to say the patient had had
their antibiotics when there were no antibiotics in the hospital, for example.’ They also reinforced the hierarchies
– nurses had to try to get surgeons to do certain tasks, but the surgeons used the situation as an opportunity to
display their power and refuse.
Dixon-Woods and her team spend time in hospitals to try to understand which systems are in place and how they
are used. Not only does she find differences in approaches between hospitals, but also between units and even
between shifts. ‘Standardisation and harmonisation are two of the most urgent issues we have to tackle. Imagine
if you have to learn each new system wherever you go or even whenever a new senior doctor is on the ward. This
introduces massive risk.’
SAMPLE
Dixon-Woods compares the issue of patient safety to that of climate change, in the sense that it is a ‘problem
of many hands’, with many actors, each making a contribution towards the outcome, and there is difficulty in
identifying where the responsibility for solving the problem lies. ‘Many patient safety issues arise at the level of the
system as a whole, but policies treat patient safety as an issue for each individual organisation.’
Nowhere is this more apparent than the issue of ‘alarm fatigue’, according to Dixon-Woods. Each bed in an
intensive care unit typically generates 160 alarms per day, caused by machinery that is not integrated. ‘You have
to assemble all the kit around an intensive care bed manually,’ she explains. ‘It doesn’t come built as one like an
aircraft cockpit. This is not something a hospital can solve alone. It needs to be solved at the sector level.’
Dixon-Woods has turned to Professor Clarkson in Cambridge’s Engineering Design Centre to help. ‘Fundamentally,
my work is about asking how we can make it better and what could possibly go wrong,’ explains Clarkson. ‘We
need to look through the eyes of the healthcare providers to see the challenges and to understand where tools and
techniques we use in engineering may be of value.’ There is a difficulty, he concedes: ‘There’s no formal language
of design in healthcare. Do we understand what the need is? Do we understand what the requirements are? Can
we think of a range of concepts we might use and then design a solution and test it before we put it in place? We
seldom see this in healthcare, and that’s partly driven by culture and lack of training, but partly by lack of time.’
Dixon-Woods agrees that healthcare can learn much from engineers. ‘There has to be a way of getting our two
sides talking,’ she says. ‘Only then will we be able to prevent tragedies like the death of Mary.’
SAMPLE
7. What point is made about the death of a female patient called Mary?
A It was entirely preventable.
B Nobody was willing to accept the blame.
C Surgeons should have tried harder to save her life.
D It is the type of incident which is becoming increasingly common.
8. What is meant by the phrase ‘effort substitution’ in the second paragraph?
A Monetary resources are diverted unnecessarily.
B Time and energy is wasted on irrelevant matters.
C Staff focus their attention on a limited number of issues.
D People have to take on tasks which they are unfamiliar with.
9. By quoting Dixon-Woods in the second paragraph, the writer shows that the professor
A understands why healthcare employees have to make certain choices.
B doubts whether reward schemes are likely to put patients at risk.
C believes staff should be paid a bonus for achieving goals.
D feels the people in question have made poor choices.
10. What point is made about checklists in the third paragraph?
A Hospital staff sometimes forget to complete them.
B Nurses and surgeons are both reluctant to deal with them.
C They are an additional burden for over-worked nursing staff.
D The information recorded on them does not always reflect reality.
SAMPLE
11. What problem is mentioned in the fourth paragraph?
A failure to act promptly
B outdated procedures
C poor communication
D lack of consistency
12. What point about patient safety is the writer making by quoting Dixon-Woods’ comparison with
climate change?
A The problem will worsen if it isn’t dealt with soon.
B It isn’t clear who ought to be tackling the situation.
C It is hard to know what the best course of action is.
D Many people refuse to acknowledge there is a problem.
13. The writer quotes Dixon-Woods’ reference to intensive care beds in order to
A present an alternative viewpoint.
B illustrate a fundamental obstacle.
C show the drawbacks of seemingly simple solutions.
D give a detailed example of how to deal with an issue.
14. What difference between healthcare and engineering is mentioned in the final paragraph?
A the types of systems they use
B the way they exploit technology
C the nature of the difficulties they face
D the approach they take to deal with challenges
SAMPLE
Text 2: Migraine – more than just a headache
When a news reporter in the US gave an unintelligible live TV commentary of an awards ceremony, she became
an overnight internet sensation. As the paramedics attended, the worry was that she’d suffered a stroke live on
air. Others wondered if she was drunk or on drugs. However, in interviews shortly after, she revealed, to general
astonishment, that she’d simply been starting a migraine. The bizarre speech difficulties she experienced are
an uncommon symptom of aura, the collective name for a range of neurological symptoms that may occur just
before a migraine headache. Generally aura are visual – for example blind spots which increase in size, or have a
flashing, zig-zagging or sparkling margin, but they can include other odd disturbances such as pins and needles,
memory changes and even partial paralysis.
Migraine is often thought of as an occasional severe headache, but surely symptoms such as these should tell
us there’s more to it than meets the eye. In fact many scientists now consider it a serious neurological disorder.
One area of research into migraine aura has looked at the phenomenon known as Cortical Spreading Depression
(CSD) – a storm of neural activity that passes in a wave across the brain’s surface. First seen in 1944 in the brain
of a rabbit, it’s now known that CSD can be triggered when the normal flow of electric currents within and around
brain cells is somehow reversed. Nouchine Hadjikhani and her team at Harvard Medical School managed to record
an episode of CSD in a brain scanner during migraine aura (in a visual region that responds to flickering motion),
having found a patient who had the rare ability to be able to predict when an aura would occur. This confirmed a
long-suspected link between CSD and the aura that often precedes migraine pain. Hadjikhani admits, however, that
other work she has done suggests that CSD may occur all over the brain, often unnoticed, and may even happen in
healthy brains. If so, aura may be the result of a person’s brain being more sensitive to CSD than it should be.
Hadjikhani has also been looking at the structural and functional differences in the brains of migraine sufferers. She
and her team found thickening of a region known as the somatosensory cortex, which maps our sense of touch
in different parts of the body. They found the most significant changes in the region that relates to the head and
face. ‘Because sufferers return to normal following an attack, migraine has always been considered an episodic
problem,’ says Hadjikhani. ‘But we found that if you have successive strikes of pain in the face area, it actually
increases cortical thickness.’
Work with children is also providing some startling insights. A study by migraine expert Peter Goadsby, who splits
his time between King’s College London and the University of California, San Francisco, looked at the prevalence
of migraine in mothers of babies with colic - the uncontrolled crying and fussiness often blamed on sensitive
stomachs or reflux. He found that of 154 mothers whose babies were having a routine two-month check-up, the
migraine sufferers were 2.6 times as likely to have a baby with colic. Goadsby believes it is possible that a baby
with a tendency to migraine may not cope well with the barrage of sensory information they experience as their
nervous system starts to mature, and the distress response could be what we call colic.
SAMPLE
Linked to this idea, researchers are finding differences in the brain function of migraine sufferers, even between
attacks. Marla Mickleborough, a vision specialist at the University of Saskatchewan in Saskatoon, Canada, found
heightened sensitivity to visual stimuli in the supposedly ‘normal’ period between attacks. Usually the brain comes
to recognise something repeating over and over again as unimportant and stops noticing it, but in people with
migraine, the response doesn’t diminish over time. ‘They seem to be attending to things they should be ignoring,’
she says.
Taken together this research is worrying and suggests that it’s time for doctors to treat the condition more
aggressively, and to find out more about each individual’s triggers so as to stop attacks from happening. But
there is a silver lining. The structural changes should not be likened to dementia, Alzheimer’s disease or ageing,
where brain tissue is lost or damaged irreparably. In migraine, the brain is compensating. Even if there’s a genetic
predisposition, research suggests it is the disease itself that is driving networks to an altered state. That would
suggest that treatments that reduce the frequency or severity of migraine will probably be able to reverse some of
the structural changes too. Treatments used to be all about reducing the immediate pain, but now it seems they
might be able to achieve a great deal more.
SAMPLE
15. Why does the writer tell the story of the news reporter?
A to explain the causes of migraine aura
B to address the fear surrounding migraine aura
C to illustrate the strange nature of migraine aura
D to clarify a misunderstanding about migraine aura
16. The research by Nouchine Hadjikhani into CSD
A has less relevance than many believe.
B did not result in a definitive conclusion.
C was complicated by technical difficulties.
D overturned years of accepted knowledge.
17. What does the word ‘This’ in the second paragraph refer to?
A the theory that connects CSD and aura
B the part of the brain where auras take place
C the simultaneous occurrence of CSD and aura
D the ability to predict when an aura would happen
18. The implication of Hadjikhani’s research into the somatosensory cortex is that
A migraine could cause a structural change.
B a lasting treatment for migraine is possible.
C some diagnoses of migraine may be wrong.
D having one migraine is likely to lead to more.
SAMPLE
19. What does the writer find surprising about Goadsby’s research?
A the idea that migraine may not run in families
B the fact that migraine is evident in infanthood
C the link between childbirth and onset of migraine
D the suggestion that infant colic may be linked to migraine
20. According to Marla Mickleborough, what is unusual about the brain of migraine sufferers?
A It fails to filter out irrelevant details.
B It struggles to interpret visual input.
C It is slow to respond to sudden changes.
D It does not pick up on important information.
21. The writer uses the phrase ‘a silver lining’ in the final paragraph to emphasise
A the privileged position of some sufferers.
B a more positive aspect of the research.
C the way migraine affects older people.
D the value of publicising the research.
22. What does the writer suggest about the brain changes seen in migraine sufferers?
A Some of them may be beneficial.
B They are unlikely to be permanent.
C Some of them make treatment unnecessary.
D They should still be seen as a cause for concern.
END OF READING TEST

SAMPLE
Sample Test 2

PART A
PART A: QUESTIONS: 1 – 20
1 D
2 C
3 B
4 D
5 A
6 B
7 C
8 headache(s)
9 hepatitis C OR hep C
10 ALF OR acute liver failure
11 renal failure (NOT: renal dysfunction)
12 methionine
13 (activated) charcoal
14 speed of absorption
15 right upper quadrant
16 nausea OR vomiting OR nausea and vomiting OR vomiting and nausea
17 enzyme-inducing
18 100 OR a hundred OR one hundred
19 12 OR twelve
20 supportive (treatment)
SAMPLE

Sample Test 2

PARTS B & C
1 C can delegate responsibility for the cupboard keys to another ward.

2 A give a valid reason for conducting it.
3 A help maximise its efficiency.
4 B They enable a patient to receive more of the prescribed medicine.
5 A benefits to patients of using bedrails can outweigh the dangers.
6 A They may be useful for patients who are not fully responsive.
7 A It was entirely preventable.

8 C Staff focus their attention on a limited number of issues.
9 A understands why healthcare employees have to make certain choices.
10 D The information recorded on them does not always reflect reality.
11 D lack of consistency
12 B It isn’t clear who ought to be tackling the situation.
13 B illustrate a fundamental obstacle.
14 D the approach they take to deal with challenges
15 C to illustrate the strange nature of migraine aura

16 B did not result in a definitive conclusion.
17 C the simultaneous occurrence of CSD and aura
18 A migraine could cause a structural change.
19 D the suggestion that infant colic may be linked to migraine
20 A It fails to filter out irrelevant details.
21 B a more positive aspect of the research.
22 B They are unlikely to be permanent.
Page 126

5
Practice Test 1
Page 127
Page 128 Scanned by CamScanner
Eventually, after destroying relationships with her loved ones, bankrupting her
savings, and hitting rock-bottom, Jane turned to a local opioid addiction clinic
for help. At the clinic, they put her on Methadone, a long-acting opioid agonist
that is standard for addiction treatment. It binds to the mu-opioid receptors,
prevents withdrawal symptoms, reduces cravings, and can also provide a level of
pain relief. Of course, as an opioid agonist, methadone serves as a substitute for
the primary addiction, meaning many of the issues associated with long-term
opioid usage remain. Patients must often begin treatment with daily visits, which
can be disruptive. Fortunately for Jane, these visits are her first steps towards
putting her life back together. As Jane’s road to recovery is likely to be long and
fraught with difficulty, many doctors are led to wonder: does she have any other
options?
One of the increasingly popular alternatives to methadone is buprenorphine, a

partial mu-opioid agonist. Aside from its unique mechanism of action (MOA),
there are two major differences when compared to Methadone: first, it can be
administered as oral tablets, sublingual/buccal films, and a long-acting implant,
second, It can be prescribed month-to-month from a clinician’s office directly to
a local pharmacy. These factors make it much easier to use in the community,
and are ideal for patients who cannot visit a methadone clinic every day.
To initiate buprenorphine, a patient must already be in a mild state of withdrawal

due to the high affinity for the mu-opioid receptor displacing other opioids. This
means that patients generally transition best from a short-acting opioid like
heroin or oxycodone rather than a long-acting opioid agonist like Methadone,
given the length of time needed until mild withdrawal occurs. As Jane had been
using opioids for a long time prior to her admission, however, she was better
Page 49
PRACTICE SET
1. D
2. A
3. C
4. B
5. C
6. B
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7. fortified foods (and supplements)

8. low reticulocytes (reticulocytopenia)
9. laboured
10. 45
11. reticulocytes (reticulocytosis)
12. menstrual cycle
13. complications
14. size of the red blood cell
---------------------------------------------------------------------------------------
15. blood loss

16. disease of the arteries
17. bone marrow
18. Red blood cell mass
19. iron deficiency
20. unique features
Page 54
2
Kaplan Practice Test
Page 57
6
Practice Test 2
Page 149
7
Practice Test 3
Page 171
Questions 13 – 20

Answer each of the questions, 13 – 20, with a word or short phrase
from one of the texts. Each answer may include words, numbers or
both. Your answers should be correctly spelled.

13. How often should patients be advised to practice breathing exercises?
14. How often should patients with a peak expiratory flow of less than 75%

be given 10 mg of salbutamol?
15. When should patients be given 2mg of magnesium sulfate?
16. Which patients will typically need to run when completing spirometry
tests?
17. What should staff do when assessing a patient suffering from a life-
threatening panic attack?
18. Which lung function test is helpful for understanding how the patient
responds to treatment?
19. What sort of noise might patients with asthma make when breathing?
20. What is used to measure peak expiratory flow rate?
Page 64
PART B: QUESTIONS 1 TO 6
End-of-Life Decision Making

1. Remember the five priorities when caring for a dying patient:
Recognise that the end of life may be approaching.

1. Communicate with patients, families, carers and staff.
2. Involve patients and those close to them in decision-
3. making.
Support the needs of families and carers.
4. Develop an individualised plan of care for the patient.
5.
An end-of-life care plan must ensure the physical, psychological,
social and spiritual comfort of the patient, and should strive for
the best possible quality of life for the patient’s remaining time.
This includes prescribing anticipatory medications which can be
given as required, falling under the following categories which
staff are encouraged to remember as the ‘Four As’: Analgesia
(pain relief), Anxiolytics (anti-anxiety), Anti-emetics (for nausea
and vomiting), and Anti-secretory (for respiratory and airway
secretions). Any unnecessary medications, such as long-term
diabetes control and blood pressure medications can be stopped.
A Do-Not-Resuscitate (DNACPR) decision also needs to be
made.
The notice reminds staff that patients who are dying
(A) will need to be prescribed anti-emetics.

(B) might not need to continue with certain medication.
(C) should be encouraged to discuss their condition with loved
ones.
Page 65
__

3. For the attention of all medical staff:
Microbial resistance to antibiotics is on the rise and infection

with multi-resistant pathogens, such as Clostridium difficile and
MRSA amongst others, is becoming more common.
Patients receiving antibiotics are at increased risk of such

infections. As such, please be aware of our antimicrobial
prescribing guidelines, which ensure that antibiotics are only

prescribed with clear, clinical justification; evidence of infection;
and/or guaranteed medical benefit.
It is recommended that specimens should be cultured and results

obtained before commencing treatment with antibiotics, thus
only prescribing the therapy to which the microbe is sensitive.
Prescription of broad-spectrum antibiotics should be avoided
where possible, as these not only damage the normal bacteria of
the human body, but also increase microbial exposure to anti-
microbial medications, increasing their potential for developing
resistance. Review narrow-spectrum antibiotic prescriptions
within 5 days, and broad-spectrum prescriptions within 48 hours.
The purpose of this memo is to explain
(A) how to treat multi-resistant pathogens.

(B) the causes of bacterial infections.
(C) when to prescribe antibiotics.
Page 67
Part A: Texts A - D
Text A
Primary Clinical Care Guidelines: Management of Head Injuries

▪ Monitor observations including BP (blood pressure) and GCS (level of
consciousness according to the Glasgow Coma Scale 1 – 15 ) .
▪ Notify MO (Medical Officer) immediately if level of consciousness alters.
▪ Prepare for intubation if GCS is 8 or less.
▪ Maintain BP as advised by MO.
▪ Keep patient warm.
▪ If there is a rapid deterioration in GCS of 2 or more and/or if one pupil
becomes fixed and dilated, this may indicate expanding (intracranial)
haemorrhage. Consult MO immediately.
▪ Give opioids with caution to patients with head injuries.
▪ If the skin is broken, check tetanus vaccination status. Administer tetanus
containing vaccine/ immunoglobulin as appropriate.
▪ Assume all head injuries have an associated neck injury.
Text B
Page 193
Text C
Intermediate High risk
Head injury clinical features – child
risk factors factors
Age < 1 year
Witnessed loss of consciousness < 5 minutes > 5 minutes
Anterograde or retrograde amnesia Possible > 5 minutes
Mild agitation or Abnormal
Behaviour
altered behaviour drowsiness
Episodes of vomiting without other cause 3 or more
Seizure in non-epileptic patient Impact only Yes
Non-accidental injury is suspected/parental
No Yes
history is inconsistent with injury
History of coagulopathy, bleeding disorder
No Yes
or previous intracranial surgery
Comorbidities Present Present
Persistent or
Headache Yes
increasing
Motor vehicle accident < 60 kph > 60 kph
Fall 1-3 metres > 3 metres
Moderate impact High speed /
Force or unclear heavy projectile or
mechanism object
Glasgow Coma Scale 14-15 < 14
Focal neurological abnormality Nil Present
Penetrating injury
Haematoma,
/ Possible
Injury swelling or
depressed skull
laceration > 5 cm
fracture.
Text
TextDD
Advice for patients who

have received an injury to the head
● Rest quietly for the day.
● Use ‘ice packs’ over swollen or painful areas. Wrap ice cubes, frozen peas or a sports
ice pack in a towel. Do not put ice directly on the skin.
● Take simple painkillers for any headache.
● If an injured patient is discharged in the evening, make sure they are woken several
times during the night.
● Do not let the injured patient drive home.
● Do not leave them alone for the next 24 hours.
● Do not let them drink alcohol for at least 24 hours.
● Do not let them eat or drink for the first six to 12 hours (unless advised otherwise by
the MO). Then offer them food and drink in moderation.
● Do not let them take sedatives or other medication unless instructed.
● Return to the clinic immediately if the patient has repeated vomiting, ‘blacks out’,
has a seizure/fit or cannot be woken or is not responsive.
● Patient to return to clinic if they have any symptoms they or the carer are concerned
about.
Page 194
Part A
TIME: 15 minutes
● Look at the four texts, A-D, in the separate Text Booklet.

● For each question, 1-20, look through the texts, A-D, to find the relevant
information.
● Write your answers on the spaces provided in this Question Paper.
● Answer all the questions within the 15-minute time limit.
● Your answers should be correctly spelt.
Head injuries: Questions
Questions 1-5
For each question, 1-5, decide which text (A, B, C or D) the information comes from.
1 what patients should and shouldn’t do when they return home? _____
2 the possible cause of abnormality apparent in a patient’s eyes? _____
3 reasons why patients should seek medical attention after being discharged?
_____
4 procedures to follow dependent on the type of head injury? _____
5 past interventions and conditions to be considered when assessing risk?

_____
Page 195
Questions 6 – 11
Answer each of the questions, 6-11
, with a word or short phrase from one of the
texts. Each answer may include words, numbers or both.
Children presenting with head injuries are assessed as high risk if they have:
had memory loss lasting (6)

____________ or more
fallen (7)
____________ or more
been hit by a weighty object or one moving at (8)

____________
unusual levels of (9)

____________
a (10)
____________ which gets worse over time
Escalation: Children assessed as intermediate or high risk should undergo a (11)

____________
Questions 12 – 16
Complete the sentences below by using a word or short phrase from the text. Each
answer may include words, numbers or both.
All patients presenting with (12)

________________________
head injuries must be
referred straight to the MO.
Patients with GCS below 8 may need (13)

________________________.

The MO should be informed without delay if there is a drop in BP or change in a
patient's level of (14)

________________________.

Staff should be especially careful when administering (15)

_______________
to
head injury patients.
Head injury patients may also have an injury to their (16)

_______________.

Page 196
Questions 17 – 20
Answer the questions below. For each answer use a word or short phrase from the
text. Each answer may include words, numbers or both.
17 If there are no significant risk factors, how long after a head injury can you
discharge a patient?
________
18 What should you provide head injury patients with when you discharge them?
________
19 What should you advise patients to take to control headaches?
________
20 What can patients use to avoid contact between ice packs and their skin?
________
Page 197
Studies have shown that the most common cause of medical errors is the use of
heuristics in medical decision-making, leading to bias. Heuristics are shortcuts
taken to reach decisions quickly, based on previous patterns of disease and
similar cases seen by the doctor. Mistakes are more likely when such shortcuts
are used by junior doctors who lack the experience necessary to make such fast
decisions accurately. Tversky and Kahneman outlined seven types of heuristics
in their 1974 article: Availability heuristics are based on how easy specific
diagnoses are to recall, resulting in over-diagnosis of rare but memorable
conditions; Representativeness heuristics are based on similarity of patient
presentations to previous typical cases, leading to delayed or missed diagnoses in
atypical or non-characteristic patients; Anchoring heuristics occur when a
diagnosis is based on one piece of information only, leading to rapid conclusions
which lack evidence and early diagnosis without consideration of all available
information; Confirmation bias occurs when a diagnosis is based on a pre-
conceived idea, where the doctor pays attention to the information that supports
their theory, and evidence which challenges the diagnosis is consciously or
subconsciously ignored; Commissioning bias where a doctor acts too soon rather
than waiting to gather and review all the information first; Gambler’s Fallacy
which is where consecutive patients have the same diagnosis and so the doctor
assumes a similar patient who follows must also have the same diagnosis;
Fundamental Attribution Error which is the tendency to blame patients rather
than their circumstances for their poor health.
Research shows that the best way to avoid medical errors in diagnosis is to
consider several hypotheses, known as “differential diagnoses”, and investigate
them all equally until the one with the most supporting evidence is found and
agreed upon. Use of heuristics and the resultant flawed decision-making could
be prevented by reducing work stresses and pressures on medical
professionals. One way to achieve this would be to reduce working
hours and shift durations in order to prevent sleep deprivation in
medical staff, which is known to hinder focus, thus creating a safer
medical environment for both staff and patients.
Page 73
2. What do we learn about the use of TENS machines?
A Evidence for their efficacy is unconfirmed.

B They are recommended in certain circumstances.
C More research is needed on their possible side effects.
Update on TENS machines

The Association of Chartered Physiotherapists in Women’s Health has an expert panel which
could not find any reports suggesting that negative effects are produced when TENS has
been used during pregnancy. However, in clinical practice, TENS is not the first treatment of
choice for women presenting with musculoskeletal pain during pregnancy. The initial
treatment should be aimed at correcting any joint or muscle dysfunction, and a rehabilitation
programme should be devised. However, if pain remains a significant factor, then TENS is
preferable to the use of strong medication that could cross the placental barrier and affect
the foetus. No negative effects have been reported following the use of this modality during
any of the stages of pregnancy. Therefore, TENS is preferable for the relief of pain.
3. If surgical instruments have been used on a patient suspected of having prion

disease, they
A must be routinely destroyed as they cannot be reused.

B may be used on other patients provided the condition has been ruled out.
C should be decontaminated in a particular way before use with other
patients.
Guidelines: Invasive clinical procedures in patients with suspected prion disease

It is essential that patients suspected of suffering from prion disease are identified prior to any
surgical procedure. Failure to do so may result in exposure of individuals on whom any surgical
equipment is subsequently used. Prions are inherently resistant to commonly used
disinfectants and methods of sterilisation. This means that there is a possibility of transmission
of prion disease to other patients, even after apparently effective methods of decontamination
or sterilisation have been used. For this reason, it may be necessary to destroy instruments
after use on such a patient, or to quarantine the instrument until the diagnosis is either
confirmed, or an alternative diagnosis is established. In any case, the instruments can be used
for the same patient on another occasion if necessary.
Page 199
4. The email suggests that POCT devices
A should only be used in certain locations.

B must be checked regularly by trained staff.
C can produce results that may be misinterpreted.
To: All Staff
Subject: Management of Point of Care Testing (POCT) Devices
Due to several recent incidents associated with POCT devices, staff are requested to read
the following advice from the manufacturer of the devices.
The risks associated with the use of POCT devices arise from Management of Point of Care
Testing Devices Version 4 January 2014, the inherent characteristics of the devices
themselves and from the interpretation of the results they provide. They can be prone to
user errors arising from unfamiliarity with equipment more usually found in the laboratory.
User training and competence is therefore crucial.
5. It’s permissible to locate a baby’s identification band somewhere other than the ankles
when
A the baby is being moved due to an emergency.

B the bands may interfere with treatment.
C the baby is in an incubator.
Identification bands for babies

The identification bands should be located on the baby’s ankles with correct identification
details unless the baby is extremely premature and/or immediate vascular access is
required. If for any reason the bands need to be removed, they should be relocated to the
wrists or if this is not possible, fixed visibly to the inside of the incubator. Any ill-fitting or
missing labels should be replaced at first check. Identity bands must be applied to the
baby’s ankles at the earliest opportunity as condition allows and definitely in the event of
fire evacuation or transportation.
Page 200
6. What is the memo doing?
A providing an update on the success of new guidelines
B reminding staff of the need to follow new guidelines
C announcing the introduction of new guidelines
Memo: Administration of antibiotics
After a thorough analysis and review, our peri-operative services, in conjunction with the
Departments of Surgery and Anaesthesia, decided to change the protocols for the
administration of pre-operative antibiotics and established a series of best practice
guidelines. This has resulted in a significant improvement in the number of patients
receiving antibiotics within the recommended 60 minutes of their incision. A preliminary
review of the total hip and knee replacements performed in May indicates that 88.9% of
patients received their antibiotics on time.
Page 201
Part C
In this part of the test, there are two texts about different aspects of health care. For
questions 1 to 8, choose the answer (A, B, C or D) which you think fits best according to
the text.
Write your answers on the separate Answer Sheet.
Detecting Carbon Monoxide Poisoning
Carbon Monoxide (CO) poisoning is the single most common source of poisoning injury
treated in US hospital emergency departments. While its presentation is not uncommon, the
diverse symptoms that manifest themselves do not lead most clinicians to consider
carboxyhemoglobinemia when attempting a diagnosis. The symptoms can be mistaken for
those of many other illnesses including food poisoning, influenza, migraine headache, or
substance abuse.
What's more, in an attempt to find the causative agent for the symptoms, many
unnecessary, and sometimes resource-intensive, diagnostics may be ordered, to no avail.
For example, because the symptoms of CO poisoning may mimic an intracranial bleed, the
time needed to obtain a negative result may hold up a proper diagnosis as well as
needlessly increasing healthcare costs. Of even greater concern, however, is that during
such delays patients may find that their symptoms abate and their health improves as the
hidden culprit, CO, is flushed from the blood during the normal ventilation patterns.
Indeed, multiple reports have shown patients being discharged and returned to the very
environment where exposure to CO took place. Take the case of a 67-year-old man who
sought medical help after three days of lightheadedness, vertigo, stabbing chest pain,
cough, chills and headache. He was admitted, evaluated and discharged with a diagnosis of
viral syndrome. Ten days later, he returned to the Emergency Department with vertigo,
palpitations and nausea but was sent home for outpatient follow-up. Four days later, he
presented again with diarrhea and severe chest pain, collapsing to the floor. This time, he
was admitted to the Coronary Care Unit with acute myocardial infarction. Among the results
of a routine arterial blood gas analysis there, it was found that his carboxyhemoglobin
(COHb) levels were 15.6%. A COHb level then obtained on his wife was 18.1%. A rusted
furnace was found to be the source.
Page 202
There are two main types of CO poisoning: acute, which is caused by brief exposure to a
high level of carbon monoxide, and chronic or subacute, which results from long exposure to
a low level of CO. Patients with acute CO poisoning are more likely to present with more
serious symptoms, such as cardiopulmonary problems, confusion, syncope, coma, and
seizure. Chronic poisoning is generally associated with the less severe symptoms. Low-level
exposure can exacerbate angina and chronic obstructive pulmonary disease, and patients
with coronary artery disease are at risk for ischemia and myocardial infarction even at low
levels of CO.
Patients that present with low COHb levels correlate well with mild symptoms of CO
poisoning, as do cases that register levels of 50-70%, which are generally fatal. However,
intermediate levels show little correlation with symptoms or with prognosis. One thing that is
certain about COHb levels is that smokers present with higher levels than do non-smokers.
The COHb level in non-smokers is approximately one to two percent. In patients who
smoke, a baseline level of nearly five percent is considered normal, although it can be as
high as 13 percent. Although COHb concentrations between 11 percent and 30 percent can
produce symptoms, it is important to consider the patient's smoking status.
Regardless of the method of detection used in emergency department care, several other
variables make assessing the severity of the CO poisoning difficult. The length of time since
CO exposure is one such factor. The half-life of CO is four to six hours when the patient is
breathing room air, and 40-60 minutes when the patient is breathing 100 percent oxygen. If
a patient is given oxygen during their transport to the emergency department, it will be
difficult to know when the COHb level hit its highest point. In addition, COHb levels may not
fully correlate with the clinical condition of CO-poisoned patients because the COHb level in
the blood is not an absolute index of compromised oxygen delivery at the tissue level.
Furthermore, levels may not match up to specific signs and symptoms: patients with
moderate levels will not necessarily appear sicker than patients with lower levels.
In hospitals, the most common means of measuring CO exposure has traditionally been
through the use of a laboratory CO-Oximeter. A blood sample, under a physician order, is
drawn from either venous or arterial vessel and injected into the device. Using a method
called spectrophotometric blood gas analysis, this then measures the invasive blood
sample. Because the CO-Oximeter can only yield a single, discrete reading for each aliquot
of blood sampled, the reported value is a non-continuous snapshot of the patient's condition
at the particular moment that the sample was collected. It does, however, represent a step in
the right direction. One study found that in hospitals lacking such a device, the average time
Page 203
Text 1: Questions 7 to 14
1 In the first paragraph, what reason for the misdiagnosis of CO poisoning is highlighted?
A the limited experience physicians have of it
B the wide variety of symptoms associated with it
C the relative infrequency with which it is presented
D the way it is concealed by pre-existing conditions
2 In the second paragraph, the writer stresses the danger of delays in diagnosis leading to
A the inefficient use of scarce resources.
B certain symptoms being misinterpreted.
C a deterioration in the patient's condition.
D the evidence of poisoning disappearing.
3 The 67-year-old man's CO poisoning was only successfully diagnosed as a result of
A attending an outpatient clinic.
B his wife being similarly affected.
C undergoing tests as an inpatient.
D his suggesting the probable cause.
4 In the fourth paragraph, confusion is given as a symptom of
A short-term exposure to high levels of CO.
B repeated exposure to varying levels of CO.
C a relatively low overall level of exposure to CO.
D sustained exposure to CO over an extended period.
Page 204
5 In the fifth paragraph, what point is made about COHb levels?
A They fail to detect CO poisoning in habitual smokers.
B They are a generally reliable indicator of CO poisoning.
C They correlate very well with extreme levels of CO poisoning.
D They are most useful in determining intermediate levels of CO poisoning.
6 The phrase 'one such factor' in the sixth paragraph refers to
A a type of care.
B a cause of difficulty.
C a method of detection.
D a way of making an assessment.
7 One result of administering oxygen to CO poisoned patients in transit is that
A it becomes harder to ascertain when the COHb level peaked.
B it may lead to changes in the type of symptoms observed.
C it could artificially inflate the COHb level in the short term.
D it affects the ability to assess the effects at tissue level.
8 What reservation about the CO-Oximeter does the writer express?
A It does not always give an immediate result.
B Its use needs to be approved by a physician.
C It requires a skilled analyst to interpret the readings.
D It does not show variations in the patient's condition.
Page 205
A course of ECT treatments does not have a standard regimen. Generally, most patients
require between six to twelve treatments, but the actual endpoint is determined by the level
of improvement. ECT is often given two to three times a week, usually on a
Monday/Wednesday/Friday schedule with psychiatric symptoms and testing carried out on a
regular basis to monitor progress. Dana starts Monday by being NPO (nothing by mouth)
except for any necessary medications. This reduces the chance for aspiration under
anaesthesia during the seizure. She will be taken down to the ECT suite where an
anaesthesiologist, psychiatrist, and nurse will greet her. She will be placed in a supine
position with EEG monitoring to determine the quality of the seizure given. She will have
electrodes placed on her head bitemporally, bifrontally, or unilaterally on the right. In this
case, given her life-threatening catatonia, we will use the bitemporal position. The
anesthesiologist will then induce anaesthesia, first preoxygenating the patient, then
administering anticholinergic agent to reduce oral secretions, anaesthesic medication, muscle
relaxation medication, and any cardiovascular prophylaxis as needed.
Once the patient is sufficiently sedated, a brief (0.5 to 2.0 milliseconds) electrical pulse will
be introduced at a level determined to reliably cause a seizure. A therapeutic ECT seizure
should last at least 15 seconds but no more than 180 seconds. Dana will be monitored for
thirty to sixty minutes once this has finished, to ensure her recovery. The goal is for further
treatments to reduce her symptoms and enable her to eat, drink, communicate, and move
again. Of course, there are adverse effects that must be considered. Anaesthesia can cause
nausea, aspiration pneumonia, dental and tongue injuries. The seizure itself can cause
cardiovascular issues, and fractures in patients with osteoporosis, and can temporarily impair
cognition and memory. It is advised that patients do not make any major or financial
decisions during or after ECT treatment, and patients must refrain from driving until a few
weeks after the last session.
For most patients, one treatment may be all that is needed. For some, continuation
of ECT as a single session every couple of weeks may help to prevent relapse.
Maintenance treatment for patients with chronically recurring psychiatric illness
may also be appropriate. The scheduling of these sessions generally depends on
the patient’s needs and episodes, sometimes even going on indefinitely. In Dana’s
case, a few treatments are all that is needed to resolve her catatonia and soon she
will be healthy enough to be discharged home with outpatient follow-up for her
mental health management.
Page 78
Part B
Part c
Page 207
9
Practice Test 5
Page 208
Sedation: Texts
Text A
Procedural sedation and analgesia for adults in the emergency department
Patients in the emergency department often need to undergo painful, distressing or unpleasant
diagnostic and therapeutic procedures as part of their care. Various combinations of analgesic,
sedative and anaesthetic agents are commonly used for the procedural sedation of adults in the
emergency department.
Although combinations of benzodiazepines and opioids have generally been used for procedural
sedation, evidence for the use of other sedatives is emerging and is supported by guidelines
based on randomised trials and observational studies. Patients in pain should be provided with
analgesia before proceeding to more general sedation. The intravenous route is generally the
most predictable and reliable method of administration for most agents.
Local factors, including availability, familiarity, and clinical experience will affect drug choice, as
will safety, effectiveness, and cost factors. There may also be cost savings associated with
providing sedation in the emergency department for procedures that can be performed safely in
either the emergency department or the operating theatre.
Text B
Levels of sedation as described by the American Society of Anesthesiologists
Non-dissociative sedation
• Minimal sedation and analgesia: essentially mild anxiolysis or pain control. Patients respond
normally to verbal commands. Example of appropriate use: changing burns dressings
• Moderate sedation and analgesia: patients are sleepy but also aroused by voice or light
touch. Example of appropriate use: direct current cardioversion
• Deep sedation and analgesia: patients require painful stimuli to evoke a purposeful response.
Airway or ventilator support may be needed. Example of appropriate use: major joint
reduction
• General anesthesia: patient has no purposeful response to even repeated painful stimuli.
Airway and ventilator support is usually required. Cardiovascular function may also be
impaired. Example of appropriate use: not appropriate for general use in the emergency
department except during emergency intubation.
Dissociative sedation
Dissociative sedation is described as a trance-like cataleptic state characterised by profound
analgesia and amnesia, with retention of protective airway reflexes, spontaneous respirations,
and cardiopulmonary stability. Example of appropriate use: fracture reduction.
[CANDIDATE NO.] READING TEXT BOOKLET PART A 02/04

Page 209
Text C
Drug administration: General principles

International consensus guidelines recommend that minimal sedation – for example, with 50% nitrous oxide-
oxygen blend – can be administered by a single physician or nurse practitioner with current life support
certification anywhere in the emergency department. Guidelines recommend that for moderate and
dissociative sedation using intravenous agents, a physician should be present to administer the sedative, in
addition to the practitioner carrying out the procedure.
For moderate sedation, resuscitation room facilities are recommended, with continuous cardiac and oxygen
saturation monitoring, non-invasive blood-pressure monitoring, and consideration of capnography (monitoring
of the concentration or partial pressure of carbon dioxide in the respiratory gases).
During deep sedation, capnography is recommended, and competent personnel should be present to provide
cardiopulmonary rescue in terms of advanced airway management and advanced life support.
Text D
Drugs used for procedural sedation and analgesia in adults in the emergency department
Class Drug Dosage Advantages Cautions
Opioids Fentanyl 0.5-1 µg/kg over 2 Short acting analgesic; May cause apnoea,
mins reversal agent (naloxone) respiratory depression,
available bradycardia, dysphoria,
muscle rigidity, nausea and
vomiting
Morphine 50-100 µg/kg then Reversal agent (naloxone); Slow onset and peak effect
0.8-1 mg/h prolonged analgesic time; less reliable
Remifentanil 0.025-0.1 µg/kg/ Ultra-short acting; no solid Difficult to use without an
min organ involved in infusion pump
metabolic clearance
Benzodiazepines Midazolam Small doses of Minimal effect on No analgesic effect; may
0.02-0.03 mg/kg respiration; reversal agent cause hypotension
until clinical effect (flumazenil)
achieved; repeat
dosing of 0.5-1 mg
with total dose ≤
5mg
Volatile agents Nitrous oxide 50% nitrous oxide - Rapid onset and recovery; Acute tolerance may
50% oxygen cardiovascular and develop; specialised
mixture respiratory stability equipment needed
Propofol Propofol Infusion of 100 Rapid onset; short-acting; May cause rapidly
µg/kg/min for 3-5 anticonvulsant properties deepening sedation, airway
min then reduce obstruction, hypotension
to~50 µg/kg/min
Phencyclidines Ketamine 0.2-0.5 mg/kg Rapid onset; short-acting; Avoid in patients with
over 2-3 min potent analgesic even at history of psychosis; may
low doses; cardiovascular cause nausea and vomiting
stability
Etomidate Etomidate 0.1-0.15 mg/kg Rapid onset; short-acting; May cause pain on
may re-administer cardiovascular stability injection, nausea, vomiting;
caution when using in
patients with seizure
disorders/epilepsy – may
induce seizures
END OF PART A
[CANDIDATE NO.] READING TEXT BOOKLET PART A 03/04

Page 210

Part A
TIME: 15 minutes
Sedation: Questions
Questions 1-7
For each question, 1-7, decide which text (A, B, C or D) the information comes from. You may use
any letter more than once.
1 the point at which any necessary pain relief should be given? ____________________
2 the benefits and drawbacks of specific classes of drugs? ____________________
3 financial considerations when making decisions about sedation? ____________________
4 typical procedures carried out under various sedation levels? ____________________
5 measures to be taken to ensure a patient’s stability under sedation? ____________________
6 reference to research into alternative sedative agents? ____________________
7 patients’ levels of sensory awareness when sedated? ____________________
Questions 8-14
Answer each of the questions, 8-14, with a word or short phrase from one of the texts. Each answer
may include words, numbers or both.
8 What class of drug is traditionally administered together with opioids for the purpose of
procedural sedation?
____________________________________________________________________
9 What level of sedation is appropriate for changing burns dressings?

____________________________________________________________________
[CANDIDATE NO.] READING QUESTION PAPER PART A 02/04

Page 211
Part B
In this part of the test, there are six short extracts relating to the work of health professionals. For
questions 1-6, choose answer (A, B or C) which you think fits best according to the text.
1. The manual states that the wheelchair should not be used
A inside buildings.
B without supervision.
C on any uneven surfaces.
Manual extract: Kuschall ultra-light wheelchair
Intended use
The active wheelchair is propelled manually and should only be used for independent or assisted
transport of a disabled patient with mobility difficulties. In the absence of an assistant, it should only
be operated by patients who are physically and mentally able to do so safely (e.g., to propel
themselves, steer, brake, etc.). Even where restricted to indoor use, the wheelchair is only suitable
for use on level ground and accessible terrain. This active wheelchair needs to be prescribed and fit
to the individual patient’s specific health condition. Any other or incorrect use could lead hazardous
situations to arise.


Page 213
2. These guidelines contain instructions for staff who
A need to screen patients for MRSA.
B are likely to put patients at risk from MRSA.
C intend to treat patients who are infected with MRSA.
MRSA Screening guidelines
It may be necessary to screen staff if there is an outbreak of MRSA within a ward or department.
Results will normally be available within three days, although occasionally additional tests need to
be done in the laboratory. Staff found to have MRSA will be given advice by the Department of
Occupational Health regarding treatment. Even minor skin sepsis or skin diseases such as
eczema, psoriasis or dermatitis amongst staff can result in widespread dissemination of
staphylococci. If a ward has an MRSA problem, staff with any of these conditions (colonised or
infected) must contact Occupational Health promptly, so that they can be screened for MRSA
carriage. Small cuts and/or abrasions must always be covered with a waterproof plaster. Staff with
infected lesions must not have direct contact with patients and must contact Occupational Health.

Page 214
3. The main point of the notice is that hospital staff
A need to be aware of the relative risks of various bodily fluids.
B should regard all bodily fluids as potentially infectious.
C must review procedures for handling bodily fluids.
Infection prevention
Infection control measures are intended to protect patients, hospital workers and others in the
healthcare setting. While infection prevention is most commonly associated with preventing HIV
transmission, these procedures also guard against other blood borne pathogens, such as hepatitis B and
C, syphilis and Chagas disease. They should be considered standard practice since an outbreak of
enteric illness can easily occur in a crowded hospital.
Infection prevention depends upon a system of practices in which all blood and bodily fluids, including
cerebrospinal fluid, sputum and semen, are considered to be infectious. All such fluids from all people
are treated with the same degree of caution, so no judgement is required about the potential infectivity
of a particular specimen. Hand washing, the use of barrier protection such as gloves and aprons, the
safe handling and disposal of ‘sharps’ and medical waste and proper disinfection, cleaning and
sterilisation are all part of creating a safe hospital.


Page 215
4. What do nursing staff have to do?
A train the patient how to control their condition with the use of an insulin pump
B determine whether the patient is capable of using an insulin pump appropriately
C evaluate the effectiveness of an insulin pump as a long-term means of treatment
Extract from staff guidelines: Insulin pumps
Many patients with diabetes self-medicate using an insulin pump. If you're caring for a hospitalised
patient with an insulin pump, assess their ability to manage self-care while in the hospital. Patients
using pump therapy must possess good diabetes self-management skills. They must also have a
willingness to monitor their blood glucose frequently and record blood glucose readings,
carbohydrate intake, insulin boluses, and exercise. Besides assessing the patient's physical and
mental status, review and record pump-specific information, such as the pump's make and model.
Also assess the type of insulin being delivered and the date when the infusion site was changed
last. Assess the patient's level of consciousness and cognitive status. If the patient doesn't seem
competent to operate the device, notify the healthcare provider and document your findings.

Page 216
5. The extract states that abnormalities in babies born to mothers who took salbutamol are
A relatively infrequent.
B clearly unrelated to its use.
C caused by a combination of drugs.
Extract from a monograph: Salbutamol Sulphate Inhalation Aerosol
Pregnant women
Salbutamol has been in widespread use for many years in humans without apparent ill
consequence. However, there are no adequate and well controlled studies in pregnant women and
there is little published evidence of its safety in the early stages of human pregnancy.
Administration of any drug to pregnant women should only be considered if the anticipated benefits
to the expectant woman are greater than any possible risks to the foetus.
During worldwide marketing experience, rare cases of various congenital anomalies, including cleft
palate and limb defects, have been reported in the offspring of patients being treated with
salbutamol. Some of the mothers were taking multiple medications during their pregnancies.
Because no consistent pattern of defects can be discerned, a relationship with salbutamol use
cannot be established.

Page 217
6. What is the purpose of this extract?
A to present the advantages and disadvantages of particular procedures
B to question the effectiveness of certain ways of removing non-viable tissue
C to explain which methods are appropriate for dealing with which types of wounds
Extract from a textbook: debridement
Debridement is the removal of non-viable tissue from the wound bed to encourage wound healing. Sharp
debridement is a very quick method, but should only be carried out by a competent practitioner, and may
not be appropriate for all patients. Autolytic debridement is often used before other methods of
debridement. Products that can be used to facilitate autolytic debridement include hydrogels,
hydrocolloids, cadexomer iodine and honey. Hydrosurgery systems combine lavage with sharp
debridement and provide a safe and effective technique, which can be used in the ward environment. This
has been shown to precisely target damaged and necrotic tissue and is associated with a reduced
procedure time. Ultrasonic assisted debridement is a relatively painless method of removing non-viable
tissue and has been shown to be effective in reducing bacterial burden, with earlier transition to secondary
procedures. However, these last two methods are potentially expensive and equipment may not always be
available.

Page 218
Part C
In this part of the test, there are two texts about different aspects of healthcare. For questions 7-22,
choose the answer (A, B, C or D) which you think fits best according to the text.
Text 1: Cardiovascular benefits of exercise
Cardiovascular disease (CVD) is the leading cause of death for both men and women in the United
States. According to the American Heart Association (AHA), by the year 2030, the prevalence of
cardiovascular disease in the USA is expected to increase by 9.9%, and the prevalence of both heart
failure and stroke is expected to increase by approximately 25%. Worldwide, it is projected that CVD
will be responsible for over 25 million deaths per year by 2025. And yet, although several risk factors
are non-modifiable (age, male gender, race, and family history), the majority of contributing factors
are amenable to intervention. These include elevated blood pressure, high cholesterol, smoking,
obesity, diet and excess stress. Aspirin taken in low doses among high risk groups is also
recommended for its cardiovascular benefits.
One modifiable behaviour with major therapeutic implications for CVD is inactivity. Inactive or
sedentary behaviour has been associated with numerous health conditions and a review of several
studies has confirmed that prolonged total sedentary time (measured objectively via an
accelerometer) has a particularly adverse relationship with cardiovascular risk factors, disease, and
mortality outcomes. The cardiovascular effects of leisure time physical activity are compelling and well
documented. Adequate physical leisure activities like walking, swimming, cycling, or stair climbing
done regularly have been shown to reduce type 2 diabetes, some cancers, falls, fractures, and
depression. Improvements in physical function and weight management have also been shown, along
with increases in cognitive function, quality of life, and life expectancy.
Several occupational studies have shown adequate physical activity in the workplace also provides
benefits. Seat-bound bus drivers in London experienced more coronary heart disease than mobile
conductors working on the same buses, as do office-based postal workers compared to their
colleagues delivering mail on foot. The AHA recommends that all Americans invest in at least 30
minutes a day of physical activity on most days of the week. In the face of such unambiguous
evidence, however, most healthy adults, apparently by choice it must be assumed, remain
sedentary.
The cardiovascular beneficial effects of regular exercise for patients with a high risk of coronary
disease have also been well documented. Leisure time exercise reduced cardiovascular mortality
during a 16-year follow-up study of men in the high risk category. In the Honolulu Heart Study, elderly
men walking more than 1.5 miles per day similarly reduced their risk of coronary disease. Such
people engaging in regular exercise have also demonstrated other CVD benefits including decreased
rate of strokes and improvement in erectile dysfunction. There is also evidence of an up to 3-year
increase in lifespan in these groups.

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Among patients with experience of heart failure, regular physical activity has also been found to help
improve angina-free activity, prevent heart attacks, and result in decreased death rates. It also
improves physical endurance in patients with peripheral artery disease. Exercise programs carried out
under supervision such as cardiac rehabilitation in patients who have undergone percutaneous
coronary interventions or heart valve surgery, who are transplantation candidates or recipients, or
who have peripheral arterial disease result in significant short- and long-term CVD benefits.
Since data indicate that cardiovascular disease begins early in life, physical interventions such as
regular exercise should be started early for optimum effect. The US Department of Health and Human
Services for Young People wisely recommends that high school students achieve a minimum target of
60 minutes of daily exercise. This may be best achieved via a mandated curriculum. Subsequent
transition from high school to college is associated with a steep decline in physical activity. Provision
of convenient and adequate exercise time as well as free or inexpensive college credits for
documented workout periods could potentially enhance participation. Time spent on leisure time
physical activity decreases further with entry into the workforce. Free health club memberships and
paid supervised exercise time could help promote a continuing exercise regimen. Government
sponsored subsidies to employers incorporating such exercise programs can help decrease the
anticipated future cardiovascular disease burden in this population.
General physicians can play an important role in counselling patients and promoting exercise.
Although barriers such as lack of time and patient non-compliance exist, medical reviews support the
effectiveness of physician counselling, both in the short term and long term. The good news is that the
percentage of adults engaging in exercise regimes on the advice of US physicians has increased from
22.6% to 32.4% in the last decade. The empowerment of physicians, with training sessions and
adequate reimbursement for their services, will further increase this percentage and ensure long-term
adherence to such programmes. Given that risk factors for CVD are consistent throughout the world,
reducing its burden will not only improve the quality of life, but will increase the lifespan for millions of
humans worldwide, not to mention saving billions of health-related dollars.

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7. In the first paragraph, what point does the writer make about CVD?
A Measures to treat CVD have failed to contain its spread.
B There is potential for reducing overall incidence of CVD.
C Effective CVD treatment depends on patient co-operation.
D Genetic factors are likely to play a greater role in controlling CVD.
8. In the second paragraph, what does the writer say about inactivity?
A Its role in the development of CVD varies greatly from person to person.
B Its level of risk lies mainly in the overall amount of time spent inactive.
C Its true impact has only become known with advances in technology.
D Its long-term effects are exacerbated by certain medical conditions.
9. The writer mentions London bus drivers in order to
A demonstrate the value of a certain piece of medical advice.
B stress the need for more research into health and safety issues.
C show how important free-time activities may be to particular groups.
D emphasise the importance of working environment to long-term health.
10. The phrase 'apparently by choice' in the third paragraph suggests the writer
A believes that health education has failed the public.
B remains unsure of the motivations of certain people.
C thinks that people resent interference with their lifestyles.
D recognises that the rights of individuals take priority in health issues.

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11. In the fourth paragraph, what does the writer suggest about taking up regular exercise?
A Its benefits are most dramatic amongst patients with pre-existing conditions.
B It has more significant effects when combined with other behavioural changes.
C Its value in reducing the risks of CVD is restricted to one particular age group.
D It is always possible for a patient to benefit from making such alterations to lifestyle.
12. The writer says 'short- and long-term CVD benefits' derive from
A long distance walking.
B better cardiac procedures.
C organised physical activity.
D treatment of arterial diseases.
13. The writer supports official exercise guidelines for US high school students because
A it is likely to have more than just health benefits for them.
B they are rarely self-motivated in terms of physical activity.
C it is improbable they will take up exercise as they get older.
D they will gain the maximum long-term benefits from such exercise.
14. What does the writer suggest about general physicians promoting exercise?
A Patients are more likely to adopt effective methods under their guidance.
B They are generally seen as positive role models by patients.
C There are insufficient incentives for further development.
D It may not be the best use of their time.

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Text 2: Power of Placebo
Ted Kaptchuk is a Professor of Medicine at Harvard Medical School. For the last 15 years, he and
fellow researchers have been studying the placebo effect – something that, before the 1990s, was
seen simply as a thorn in medicine’s side. To prove a medicine is effective, pharmaceutical
companies must show not only that their drug has the desired effects, but that the effects are
significantly greater than those of a placebo control group. However, both groups often show healing
results. Kaptchuk’s innovative studies were among the first to study the placebo effect in clinical trials
and tease apart its separate components. He identified such variables as patients’ reporting bias (a
conscious or unconscious desire to please researchers), patients simply responding to doctors’
attention, the different methods of placebo delivery and symptoms subsiding without treatment – the
inevitable trajectory of most chronic ailments.
Kaptchuk’s first randomised clinical drug trial involved 270 participants who were hoping to alleviate
severe arm pain such as carpal tunnel syndrome or tendonitis. Half the subjects were instructed to take
pain-reducing pills while the other half were told they’d be receiving acupuncture treatment. But just two
weeks into the trial, about a third of participants - regardless of whether they’d had pills or acupuncture -
started to complain of terrible side effects. They reported things like extreme fatigue and nightmarish
levels of pain. Curiously though, these side effects were exactly what the researchers had warned
patients about before they started treatment. But more astounding was that the majority of participants -
in other words the remaining two-thirds - reported real relief, particularly those in the acupuncture group.
This seemed amazing, as no-one had ever proved the superior effect of acupuncture over standard
painkillers. But Kaptchuk’s team hadn’t proved it either. The ‘acupuncture’ needles were in fact retractable
shams that never pierced the skin and the painkillers were actually pills made of corn starch. This study
wasn’t aimed at comparing two treatments. It was deliberately designed to compare two fakes.
Kaptchuk’s needle/pill experiment shows that the methods of placebo administration are as important as
the administration itself. It’s a valuable insight for any health professional: patients’ feelings and beliefs
matter, and the ways physicians present treatments to patients can significantly affect their health. This is
the one finding from placebo research that doctors can apply to their practice immediately. Others such
as sham acupuncture, pills or other fake interventions are nowhere near ready for clinical application.
Using placebo in this way requires deceit, which falls foul of several major pillars of medical ethics,
including patient autonomy and informed consent.

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Years of considering this problem led Kaptchuk to his next clinical experiment: what if he simply told
people they were taking placebos? This time his team compared two groups of IBS sufferers. One group
received no treatment. The other patients were told they’d be taking fake, inert drugs (from bottles
labelled ‘placebo pills’) and told also, at some length, that placebos often have healing effects. The
study’s results shocked the investigators themselves: even patients who knew they were taking placebos
described real improvement, reporting twice as much symptom relief as the no-treatment group. It hints at
a possible future in which clinicians cajole the mind into healing itself and the body – without the drugs
that can be more of a problem than those they purport to solve.
But to really change minds in mainstream medicine, researchers have to show biological evidence – a
feat achieved only in the last decade through imaging technology such as positron emission tomography
(PET) scans and functional magnetic resonance imaging (MRI). Kaptchuk’s team has shown with these
technologies that placebo treatments affect the areas of the brain that modulate pain reception. ‘It’s those
advances in “hard science”’, said one of Kaptchuk’s researchers, ‘that have given placebo research a
legitimacy it never enjoyed before’. This new visibility has encouraged not only research funds but also
interest from healthcare organisations and pharmaceutical companies. As private hospitals in the US run
by healthcare companies increasingly reward doctors for maintaining patients’ health (rather than for the
number of procedures they perform), research like Kaptchuk’s becomes increasingly attractive and the
funding follows.
Another biological study showed that patients with a certain variation of a gene linked to the release of
dopamine were more likely to respond to sham acupuncture than patients with a different variation –
findings that could change the way pharmaceutical companies conduct drug trials. Companies spend
millions of dollars and often decades testing drugs; every drug must outperform placebos if it is to be
marketed. If drug companies could preselect people who have a low predisposition for placebo response,
this could seriously reduce the size, cost and duration of clinical trials, bringing cheaper drugs to the
market years earlier than before.

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15. The phrase ‘a thorn in medicine’s side’ highlights the way that the placebo effect
A varies from one trial to another.
B affects certain patients more than others.
C increases when researchers begin to study it.
D complicates the process of testing new drugs.
16. In the first paragraph, it’s suggested that part of the placebo effect in trials is due to
A the way health problems often improve naturally.
B researchers unintentionally amplifying small effects.
C patients’ responses sometimes being misinterpreted.
D doctors treating patients in the control group differently.
17. The results of the trial described in the second paragraph suggest that
A surprising findings are often overturned by further studies.
B simulated acupuncture is just as effective as the real thing.
C patients’ expectations may influence their response to treatment.
D it’s easy to underestimate the negative effect of most treatments.
18. According to the writer, what should health professionals learn from Kaptchuk’s studies?
A The use of placebos is justifiable in some settings.
B The more information patients are given the better.
C Patients value clarity and honesty above clinical skill.
D Dealing with patients’ perceptions can improve outcomes.

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19. What is suggested about conventional treatments in the fourth paragraph?
A Patients would sometimes be better off without them.
B They often relieve symptoms without curing the disease.
C They may not work if patients do not know what they are.
D Insufficient attention is given to developing effective ones.
20. What does the phrase ‘This new visibility’ refer to?
A improvements in the design of placebo studies
B the increasing acceptance of placebo research
C innovations in the technology used in placebo studies
D the willingness of placebo researchers to admit mistakes
21. In the fifth paragraph, it is suggested that Kaptchuk’s research may ultimately benefit from
A the financial success of drug companies.
B a change in the way that doctors are paid.
C the increasing number of patients being treated.
D improved monitoring of patients by healthcare providers.
22. According to the final paragraph, it would be advantageous for companies to be able to use
genetic testing to
A understand why some patients don’t respond to a particular drug.
B choose participants for trials who will benefit most from them.
C find out which placebos induce the greatest response.
D exclude certain individuals from their drug trials.
END OF READING TEST


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OET PRACTICE 5
Reading – Answer
ANSWER KEY
Reading Part A
1A
2D
3A
4B
5C
6A
7B
------------------------------------------------------
8 benzodiazepines
9 minimal sedation / minimal
10 emergency intubation / intubation
11 fracture reduction
12 Phencyclidines
13Remifentanil
14 5mg / 5milligrams / 5 mg / 5 milligrams
-------------------------------------------------------------------
15 IV / intravenous route
16 cardiovascular function
17 verbal commands
18 epileptic seizures / seizures / a seizure / an epileptic seizure / seizure
disorders
19 carbon dioxide
20 reversal agent
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Reading Part B: Questions 1-8
1C
2B
3B
4B
5A
6A
Reading Part C: Questions 7-14

7B
8B
9A
10 B
11 D
12 C
13 D
14 A
Reading Part C: Questions 15-22

15 D
16 A
17 C
18 D
19 A
20 B
21 B
22 D
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10
E2language Test I
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Sedation: Iron deficiencies
Text A
Iron deficiency and iron deficiency anaemia are common. The serum ferritin level is the most useful

indicator of iron deficiency, but interpretation can be complex. Identifying the cause of iron
deficiency is crucial. Oral iron supplements are effective first-line treatment. Intravenous iron
infusions, if required, are safe, effective and practical.
Key Points
• Measurement of the serum ferritin level is the most useful diagnostic assay for detecting iron
deficiency, but interpretation may be difficult in patients with comorbidities.
• Identifying the cause of iron deficiency is crucial; referral to a gastroenterologist is often
required.
• Faecal occult blood testing is not recommended in the evaluation of iron deficiency; a
negative result does not impact on the diagnostic evaluation.
• Oral iron is an effective first-line treatment, and simple strategies can facilitate patient
tolerance.
• For patients who cannot tolerate oral therapy or require more rapid correction of iron
deficiency, intravenous iron infusions are safe, effective and practical, given the short
infusion times of available formulations.
• Intramuscular iron is no longer recommended for patients of any age.
Text B
Treatment of infants and children
Although iron deficiency in children cannot be corrected solely by dietary change, dietary advice
should be given to parents and carers. Cows’ milk is low in iron compared with breast milk and
infant formula, and enteropathy caused by hypersensitivity to cows’ milk protein can lead to
occult gastrointestinal blood loss. Excess cows’ milk intake (in lieu of iron-rich solid foods) is the
most common cause of iron deficiency in young children. Other risk factors for dietary iron
deficiency include late introduction of or insufficient iron-rich foods, prolonged exclusive
breastfeeding and early introduction of cows’ milk.
Adult doses of iron can be toxic to children, and paediatric-specific protocols on iron
supplementation should be followed. The usual paediatric oral iron dosage is 3 to 6mg/kg
elemental iron daily. If oral iron is ineffective or not tolerated then consider other causes of
anaemia, referral to a specialist paediatrician and use of IV iron.
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Text C
AN ALGORITHM FOR THE IDENTIFICATION AND MANAGEMENT OF ADULTS WITH IRON DEFICIENCY
Patient presents with clinically suspected iron deficiency

• member of high-risk population (infants, children, menstruating or pregnant
women, vegetarians)
• clinical or laboratory evidence of iron deficiency or anaemia
• micocytosis or hypochromasia (MCV or MCH below laboratory lower limit of
normal)
• Evaluate clinically for

- potential contributors and risk factors for iron deficiency
- inflammatory states or other disorders that may influence interpretation of FBC or iron studies
• Measure serum ferritin level if not already measured
Serum ferritin <30mcg/L Serum ferritin 30-100 mcg/L Serum ferritin >100 mcg/L
Iron deficiency • Borderline iron stores • Iron deficiency unlikely

• Iron deficiency not excluded as serum • If anaemia present then consider
ferritin level may be raised because of functional iron deficiency; specialist input
inflammation may be required
Evaluate for cause (see If iron deficiency felt If inflammatory state

Box 2) to be contributory identified
• Replace iron • Correct inflammatory state

- give oral iron preparation • Selected patients may still
- if rapid correction required (poorly tolerated anaemia) benefit from iron replacement;
or oral therapy unsuccessful then give intravenous iron specialist input advised
• Re-evaluate 1 to 2 weeks after therapy to ensure iron stores are replete and anaemia improving
• Re-evaluate 3 to 6 months after therapy to ensure iron repletion is maintained and anaemia resolved
If iron deficiency recurs If anaemia identified

• repeat evaluation for additional or recurrent source of blood loss; with normal iron stores
consider all diagnoses in Box 2 • evaluate for other
• refer men aged over 40 years and women over 50 years for causes of anaemia
endoscopy and colonoscopy regardless of gastrointestinal symptoms
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Text D
END OF PART A
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E2language
Test I
E2 Language Reading Part A.1
 Look at the four texts, A-D, in the (printable) Text Booklet.
 For each question, 1-20, look through the texts, A-D, to find the relevant information.
 Write your answers on the spaces provided in the ANSWER SHEET.
 Answer all the questions within the 15-minute time limit.
Iron Deficiency: Questions
Questions 1-7
For each of the questions, 1-7, decide which text (A, B, C or D) the information comes from. You may use
any letter more than once.
1considerations when treating children with iron deficiency? ____

2 essential steps for identifying iron deficiency?
____
____
3 evaluating iron deficiency by testing for blood in stool?
____
4 risk factors associated with dietary iron deficiency?
____
5 different types of iron solutions?
6 a treatment for iron deficiency that is no longer supported?

____
7 appropriate dosage when administering IV iron infusions? ____
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Questions 8-14
Your answers should be correctly spelled.
8 What level of serum ferritin leads to a diagnosis of iron deficiency?
_____________________________________________________________
9 What is the most likely cause of iron deficiency in children?
_____________________________________________________________
10 Which form of iron can also be injected into the muscle?
_____________________________________________________________
11 What should a clinician do if iron stores are normal and anaemia is still present?
_____________________________________________________________
12 How long after iron replacement therapy should a patient be re-tested?
_____________________________________________________________
13 Which form of iron is presented in a vial?
_____________________________________________________________
14 What is the first type of treatment iron deficient patients are typically given?
_____________________________________________________________
Questions 15-20
Your answers should be correctly spelled.
In comparison to breast milk and infant formula, cows’ milk is (15)______________
Special procedures should be used because (16)________________ may be poisonous for

children.
Men over 40 and women over 50 with a recurring iron deficiency should have an (17)____________
Iron sucrose can be given to a patient no more than (18)____________
Although serum ferritin level is a good indication of deficiency, interpreting the results is sometimes
difficult (19)____________
IV iron infusions are a safe alternative when patients are unable to (20)____________
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Part B
In this part of the test, there are six short extracts relating to the work of health professionals. For
questions 1-6, choose answer (A, B or C) which you think fits best according to the text.
1. The code of conduct applies to
A doctors friending patients on Facebook.
B privacy settings when using social media.
C electronic and face to face communication.
Professional obligations
The Code of conduct contains guidance about the required standards of

professional behaviour, which apply to registered health practitioners whether
they are interacting in person or online. The Code of conduct also articulates
standards of professional conduct in relation to privacy and confidentiality of
patient information, including when using social media. For example, posting
unauthorised photographs of patients in any medium is a breach of the
patient’s privacy and confidentiality, including on a personal Facebook site or
group, even if the privacy settings are set at the highest setting (such as for a
closed, ‘invisible’ group).

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2. Why does dysphagia often require complex management?
A Because it negatively influences the cardiac system.
B Because it is difficult contrast complex and non-complex cases.
C Because it seldom occurs without other symptoms.
6.1 General principles
Dysphagia management may be complex and is often multi-factorial in nature. The

speech pathologist’s understanding of human physiology is critical. The swallowing
system works with the respiratory system. The respiratory system is in turn influenced
by the cardiac system, and the cardiac system is affected by the renal system. Due to
the physiological complexities of the human body, few clients present with dysphagia in
isolation.
6.2 Complex vs. non-complex cases
Broadly the differentiation between complex and non-complex cases relates to an

appreciation of client safety and reduction in risk of harm. All clinicians, including new
graduates, should have sufficient skills to appropriately assess and manage non-
complex cases. Where a complex client presents, the skills of an advanced clinician are
required. Supervision and mentoring should be sought for newly graduated clinicians or
those with insufficient experience to manage complex cases.
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3. The main point of the extract is
A how to find documents about infection control in Australia.
B that dental practices must have a guide for infection control.
C that dental infection control protocols must be updated.
1 Documentation
1.1 Every place where dental care is provided must have the following documents in
either hard copy or electronic form (the latter includes guaranteed Internet access).
Every working dental practitioner and all staff must have access to:
a). a manual setting out the infection control protocols and procedures used in that
practice, which is based on the documents listed at sections 1.1(b), (c) and (d) of
these guidelines and with reference to the concepts in current practice noted in the
documents listed under References in these guidelines
b). The current Australian Dental Association Guidelines for Infection Control
(available at: http://www.ada.org.au)
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4. Negative effects from prescription drugs are often
A avoidable in young people.

B unpredictable in the elderly.
C caused by miscommunication.

Reasons for Drug-Related Problems: Manual for Geriatrics Specialists

Adverse drug effects can occur in any patient, but certain characteristics of the elderly
make them more susceptible. For example, the elderly often take many drugs
(polypharmacy) and have age-related changes in pharmacodynamics and
pharmacokinetics; both increase the risk of adverse effects.
At any age, adverse drug effects may occur when drugs are prescribed and taken
appropriately; e.g., new-onset allergic reactions are not predictable or preventable.
However, adverse effects are thought to be preventable in almost 90% of cases in the
elderly (compared with only 24% in younger patients). Certain drug classes are commonly
involved: antipsychotics, antidepressants, and sedative-hypnotics.
In the elderly, a number of common reasons for adverse drug effects, ineffectiveness, or
both are preventable. Many of these reasons involve inadequate communication with
patients or between health care practitioners (particularly during health care transitions).
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5. The guideline tries to use terminology that
A presents value-free information about different social groups.
B distinguishes disadvantaged groups from the traditional majority.
C clarifies the proportion of each race, gender and culture.
Terminology
Terminology in this guideline is a difficult issue since the choice of terminology used
to distinguish groups of persons can be personal and contentious, especially when
the groups represent differences in race, gender, sexual orientation, culture or other
characteristics. Throughout the development of this guideline the panel endeavoured
to maintain neutral and non-judgmental terminology wherever possible. Terms such
as “minority”, “visible minority”, “non-visible minority” and “language minority” are used
in some areas; when doing so the panel refers solely to their proportionate numbers
within the larger population and infers no value on the term to imply less importance
or less power. In some of the recommendations the term “under-represented groups”
is used, again, to refer solely to the disproportionate representation of some citizens
in those settings in comparison to the traditional majority.

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6. What is the purpose of this extract?
A To illustrate situations where patients may find it difficult to give negative feedback.
B To argue that hospital brochures should be provided in many languages.
C To provide guidance to people who are victims of discrimination.
Special needs
Special measures may be needed to ensure everyone in your client base is aware of your consumer feedback
policy and is comfortable with raising their concerns. For example, should you provide brochures in a
language other than English?
Some people are less likely to complain for cultural reasons. For example, some Aboriginal people may be
culturally less inclined to complain, particularly to non-Aboriginal people. People with certain conditions such
as hepatitis C or a mental illness, may have concerns about discrimination that will make them less likely to
speak up if they are not satisfied or if something is wrong.
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Part C
In this part of the test, there are two texts about different aspects of healthcare. For questions 7-22,
choose the answer (A, B, C or D) which you think fits best according to the text.
Text 1: Difficult-to-treat depression
Depression remains a leading cause of distress and disability worldwide. In one country’s
survey of health and wellbeing in 2007, 7.2% of people surveyed had experienced a mood
(affective) disorder in the previous 12 months. Those affected reported a mean of 11.7
disability days when they were “completely unable to carry out or had to cut down on their
usual activities owing to their health” in the previous 4 weeks. There was also evidence of
substantial under-treatment: amazingly only 35% of people with a mental health problem had
a mental health consultation during the previous 12 months. Three-quarters of those seeking
help saw a general practitioner (GP). In the 2015–16 follow-up survey, not much had
changed. Again, there was evidence of substantial unmet need, and again GPs were the
health professionals most likely to be providing care.
While GPs have many skills in the assessment and treatment of depression, they are often
faced with people with depression who simply do not get better, despite the use of proven
psychological or pharmacological therapies. GPs are well placed in one regard, as they often
have a longitudinal knowledge of the patient, understand his or her circumstances, stressors
and supports, and can marshal this knowledge into a coherent and comprehensive
management plan. Of course, GPs should not soldier on alone if they feel the patient is not
getting better.
In trying to understand what happens when GPs feel “stuck” while treating someone with
depression, a qualitative study was undertaken that aimed to gauge the response of GPs to
the term “difficult-to-treat depression”. It was found that, while there was confusion around
the exact meaning of the term, GPs could relate to it as broadly encompassing a range of
individuals and presentations. More specific terms such as “treatment-resistant depression”
are generally reserved for a subgroup of people with difficult-to-treat depression that has
failed to respond to treatment, with particular management implications.
One scenario in which depression can be difficult to treat is in the context of physical illness.
Depression is often expressed via physical symptoms, however it is also true is that people
with chronic physical ailments are at high risk of depression. Functional pain syndromes
where the origin and cause of the pain are unclear, are particularly tricky, as complaints of
pain require the clinician to accept them as “legitimate”, even if there is no obvious physical
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cause. The use of analgesics can create its own problems, including dependence. Patients
with comorbid chronic pain and depression require careful and sensitive management and a
long-term commitment from the GP to ensure consistency of care and support.
It is often difficult to tackle the topic of depression co-occurring with borderline personality
disorder (BPD). People with BPD have, as part of the core disorder, a perturbation of affect
associated with marked variability of mood. This can be very difficult for the patient to deal
with and can feed self-injurious and other harmful behaviour. Use of mentalisation-based
techniques is gaining support, and psychological treatments such as dialectical behaviour
therapy form the cornerstone of care. Use of medications tends to be secondary, and
prescription needs to be judicious and carefully targeted at particular symptoms. GPs can
play a very important role in helping people with BPD, but should not “go it alone”, instead
ensuring sufficient support for themselves as well as the patient.
Another particularly problematic and well-known form of depression is that which occurs in
the context of bipolar disorder. Firm data on how best to manage bipolar depression is
surprisingly lacking. It is clear that treatments such as unopposed antidepressants can make
matters a lot worse, with the potential for induction of mania and mood cycle acceleration.
However, certain medications (notably, some mood stabilisers and atypical antipsychotics)
can alleviate much of the suffering associated with bipolar depression. Specialist psychiatric
input is often required to achieve the best pharmacological approach. For people with bipolar
disorder, psychological techniques and long-term planning can help prevent relapse. Family
education and support is also an important consideration.
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7. In the first paragraph, what point does the writer make about the treatment of depression?
A 75% of depression sufferers visit their GP for treatment.
B GPs struggle to meet the needs of patients with depression.
C Treatment for depression takes an average of 11.7 days a month.
D Most people with depression symptoms never receive help.
8. In the second paragraph, the writer suggests that GPs
A are in a good position to conduct long term studies on their patients.
B lack training in the treatment and assessment of depression.
C should seek help when treatment plans are ineffective.
D sometimes struggle to create coherent management plans.
9. What do the results of the study described in the third paragraph suggest?
A GPs prefer the term “treatment resistant depression” to “difficult-to-treat depression”.
B Patients with “difficult-to-treat depression” sometimes get “stuck” in treatment.
C The term “difficult-to-treat depression” lacks a precise definition.
D There is an identifiable sub-group of patients with “difficult-to-treat depression”.
10. Paragraph 4 suggests that
A prescribing analgesics is unadvisable when treating patients with depression.
B the co-occurrence of depression with chronic conditions makes it harder to treat.
C patients with depression may have undiagnosed chronic physical ailments.
D doctors should be more careful when accepting pain complaints as legitimate.
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11. According to paragraph 5, people with BPD have
A depression occurring as a result of the disorder
B noticeable mood changes which are central to their disorder.
C a tendency to have accidents and injure themselves.
D problems tackling the topic of their depression.
12. In paragraph 5, what does the phrase ‘form the cornerstone’ mean regarding BPD treatment?
A Psychological therapies are generally the basis of treatment.
B There is more evidence for using mentalisation than dialectical behaviour therapy.
C Dialectical behaviour therapy is the optimum treatment for depression.

.
D In some unusual cases prescribing medication is the preferred therapy.
13. In paragraph 6, what does the writer suggest about research into bipolar depression management?
A There is enough data to establish the best way to manage bipolar depression.
B Research hasn’t provided the evidence for an ideal management plan yet.
C A lack of patients with the condition makes it difficult to collect data on its management.
D Too few studies have investigated the most effective ways to manage this condition.
14. In paragraph 6, what does the writer suggest about the use of medications when treating bipolar
depression?
A There is evidence for the positive and negative results of different medications.
B Medications typically make matters worse rather than better.
C Medication can help prevent long term relapse when combined with family education.
D Specialist psychiatrists should prescribe medication for bipolar disorder rather than GPs.
Page 244
Text 2: Are the best hospitals managed by doctors?
Doctors were once viewed as ill-prepared for leadership roles because their selection and
training led them to become “heroic lone healers.” However, the emphasis on patient-
centered care and efficiency in the delivery of clinical outcomes means that physicians are
now being prepared for leadership. The Mayo Clinic is America’s best hospital, according to
the 2016 US News and World Report (USNWR) ranking. Cleveland Clinic comes in second.
The CEOs of both — John Noseworthy and Delos “Toby” Cosgrove — are highly skilled
physicians. In fact, both institutions have been physician-led since their inception around a
century ago. Might there be a general message here?
A study published in 2011 examined CEOs in the top-100 hospitals in USNWR in three key
medical specialties: cancer, digestive disorders, and cardiovascular care. A simple question
was asked: are hospitals ranked more highly when they are led by medically trained doctors
or non-MD professional managers? The analysis showed that hospital quality scores are
approximately 25% higher in physician-run hospitals than in manager-run hospitals. Of
course, this does not prove that doctors make better leaders, though the results are surely
consistent with that claim.
Other studies find a similar correlation. Research by Bloom, Sadun, and Van Reenen
revealed how important good management practices are to hospital performance. However,
they also found that it is the proportion of managers with a clinical degree that had the
largest positive effect; in other words, the separation of clinical and managerial knowledge
inside hospitals was associated with more negative management outcomes. Finally, support
for the idea that physician-leaders are advantaged in healthcare is consistent with
observations from many other sectors. Domain experts – “expert leaders” (like physicians in
hospitals) — have been linked with better organizational performance in settings as diverse
as universities, where scholar-leaders enhance the research output of their organizations, to
basketball teams, where former All-Star players turned coaches are disproportionately
linked to NBA success.
What are the attributes of physician-leaders that might account for this association with
enhanced organizational performance? When asked this question, Dr. Toby Cosgrove, CEO
of Cleveland Clinic, responded without hesitation, “credibility … peer-to-peer credibility.” In
other words, when an outstanding physician heads a major hospital, it signals that they have
“walked the walk”. The Mayo website notes that it is physician-led because, “This helps
ensure a continued focus on our primary value, the needs of the patient come first.” Having
spent their careers looking through a patient-focused lens, physicians moving into executive
positions might be expected to bring a patient-focused strategy.
Page 245
In a recent study that matched random samples of U.S. and UK employees with employers,
we found that having a boss who is an expert in the core business is associated with high
levels of employee job satisfaction and low intentions of quitting. Similarly, physician-leaders
may know how to raise the job satisfaction of other clinicians, thereby contributing to
enhanced organizational performance. If a manager understands, through their own
experience, what is needed to complete a job to the highest standard, then they may be
more likely to create the right work environment, set appropriate goals and accurately
evaluate others’ contributions.
Finally, we might expect a highly talented physician to know what “good” looks like when
hiring other physicians. Cosgrove suggests that physician-leaders are also more likely to
tolerate innovative ideas like the first coronary artery bypass, performed by René Favaloro at
the Cleveland Clinic in the late ‘60s. Cosgrove believes that the Cleveland Clinic unlocks
talent by giving safe space to people with extraordinary ideas and importantly, that
leadership tolerates appropriate failure, which is a natural part of scientific endeavour and
progress.
The Cleveland Clinic has also been training physicians to lead for many years. For example,
a cohort-based annual course, “Leading in Health Care,” began in the early 1990s and has
invited nominated, high-potential physicians (and more recently nurses and administrators)
to engage in 10 days of offsite training in leadership competencies which fall outside the
domain of traditional medical training. Core to the curriculum is emotional intelligence (with
360-degree feedback and executive coaching), teambuilding, conflict resolution, and
situational leadership. The course culminates in a team-based innovation project presented
to hospital leadership. 61% of the proposed innovation projects have had a positive
institutional impact. Moreover, in ten years of follow-up after the initial course, 48% of the
physician participants have been promoted to leadership positions at Cleveland Clinic.
Page 246
15. In paragraph 1, why does the writer mention the Mayo and Cleveland Clinics?
A To highlight that they are the two highest ranked hospitals on the USNWR
B To introduce research into hospital management based in these clinics
C To provide examples to support the idea that doctors make good leaders
D To reinforce the idea that doctors should become hospital CEOs
16. What is the writer’s opinion about the findings of the study mentioned in paragraph 2?
A They show quite clearly that doctors make better hospital managers.
B They show a loose connection between doctor-leaders and better management.
C They confirm that the top-100 hospitals on the USNWR ought to be physician-run.
D They are inconclusive because the data is insufficient.
17. Why does the writer mention the research study in paragraph 3?
A To contrast the findings with the study mentioned in paragraph 2
B To provide the opposite point of view to his own position
C To support his main argument with further evidence
D To show that other researchers support him
18. In paragraph 3, the phrase ‘disproportionately linked’ suggests
A all-star coaches have a superior understanding of the game.
B former star players become comparatively better coaches.
C teams coached by former all-stars consistently outperform other teams.
D to be a successful basketball coach you need to have played at a high level.
Page 247
19. In the fourth paragraph, what does the phrase “walked the walk,” imply about physician-
leaders?
A They have earned credibility through experience.
B They have ascended the ranks of their workplace.
C They appropriately incentivise employees.
D They share the same concerns as other doctors.
20. In paragraph 6, the writer suggests that leaders promote employee satisfaction because
A they are often cooperative.
B they tend to give employees positive evaluations.
C they encourage their employees not to leave their jobs.
D they understand their employees’ jobs deeply.
21. In the seventh paragraph, why is the first coronary artery bypass operation mentioned?
A To demonstrate the achievements of the Cleveland clinic
B To present René Favaloro as an exemplar of a ‘good’ doctor
C To provide an example of an encouraging medical innovation
D To show how failure naturally contributes to scientific progress
22. In paragraph 8, what was the outcome of the course “Leading in Health Care”?
A The Cleveland Clinic promoted almost half of the participants.
B 61% of innovation projects lead to participants being promoted.
C Some participants took up leadership roles outside the medical domain.
D A culmination of more team-based innovations.
Page 248
E2language
Test I- Answer
Answer Sheet
1) B
2) C
3) A
4) B
5) D
6) A
7) D
---------------------------------------------------------------------------------------------------
8) <30 mcg/L / less than 30 mcg/L / < 30 mcg / L / <30mcg/L
9) excess cow's milk / excess cow milk / excess cows' milk / excessive cow's milk / excessive cow milk /
excessive cows' milk / excess cow's milk intake / excess cow milk intake / excess cows' milk intake /
excessive cow's milk intake / excessive cow milk intake / excessive cows' milk intake
10) iron polymaltose
11) consider other cases / evaluate other causes / evaluate for other causes
12) 1 to 2 weeks / one to two weeks / 1-2 weeks / 1 - 2 weeks
13) ferric carboxymaltose
14) oral iron / oral iron supplements
---------------------------------------------------------------------------------------------------------
15) low in iron
16) adult doses of iron / adult iron doses
17) endoscopy and colonoscopy / colonoscopy and endoscopy
18) 3 times per week / three times per week / 3 times a week / three times a week / 3 times weekly / three
times weekly
19) in patients with comorbidities
20) tolerate oral iron / tolerate oral iron therapies / tolerate oral iron therapy
Page 249
Part B.1
Part C.1
_________________________
Page 250
11
E2language Test II
Page 251
Opioid dependence
Text A
Identifying opioid dependence
The International Classification of Disease, Tenth Edition [ICD-10] is a coding system created
by the World Health Organization (WHO) to catalogue and name diseases, conditions, signs
and symptoms.

The ICD-10 includes
criteria to identify dependence. According to the ICD-10
, opioid
dependence is defined by the presence of three or more of the following features at any one
time in the preceding year:

● a strong desire or sense of compulsion to take opioids
● difficulties in controlling opioid use
● a physiological withdrawal state
● tolerance of opioids
● progressive neglect of alternative interests or pleasures because of opioid use
● persisting with opioid use despite clear evidence of overtly harmful consequences.

There are other definitions of opioid dependence or ‘use disorder’ (e.g. the Diagnostic and
Statistical Manual of Mental Disorders, 5th edition, [DSM-5
]),
but the central features are the
same. Loss of control over use, continuing use despite harm, craving, compulsive use, physical
tolerance and dependence remain key in identifying problems.
Page 252
Text B
WHY NOT JUST PRESCRIBE CODEINE OR ANOTHER OPIOID?
Now that analgesics containing codeine are no longer available OTC (over the counter), patients may
request a prescription for codeine. It is important for GPs to explain that there is a lack of evidence
demonstrating the long-term analgesic efficacy of codeine in treating chronic non-cancer pain. Long-term
use of opioids has not been associated with sustained improvement in function or quality of life, and there
are increasing concerns about the risk of harm.
GPs should explain that the risks associated with opioids include tolerance leading to dose escalation,
overdose, falls, accidents and death. It should be emphasised that OTC codeine-containing analgesics
were only intended for short-term use (one to three days) and that longer-term pain management requires
a more detailed assessment of the patient's medical condition as well as clinical management.
New trials have shown that for acute pain, nonopioid combinations can be as effective as combination
analgesics containing opioids such as codeine and oxycodone. If pain isn’t managed with nonopioid
medications then consider referring the patient to a pain specialist or pain clinic.
Patient resources for pain management are freely available online to all clinicians at websites such as:
• Pain Management Network in NSW - www.aci.health.nsw.gov.au/networks/pain-management
• Australian and New Zealand College of Anaesthetists Faculty of Pain Medicine -
www.fpm.anzca.edu.au
Page 253
Text C
Page 254
Text D
Preparation for tapering

As soon as a valid indication for tapering of opioid analgesics is established, it is important to have a
conversation with the patient to explain the process and develop a treatment agreement. This agreement
could include:
• time frame for the agreement
• objectives of the taper
• frequency of dose reduction
• requirement for obtaining the prescriptions from a designated clinician
• scheduled appointments for regular review
• anticipated effects of the taper
• consent for urine drug screening
• possible consequences of failure to comply.
Before starting tapering, it needs to be clearly emphasised to the patient that reducing the dose of opioid
analgesia will not necessarily equate to increased pain and that it will, in effect, lead to improved mood
and functioning as well as a reduction in pain intensity. The prescriber should establish a therapeutic
alliance with the patient and develop a shared and specific goal.
END OF PART A
Page 255
E2language
Test II
Managing Opioid Dependence Questions 1-7

For each of the questions, 1-7, decide which text (A, B, C or D) the information
comes from. You may use any letter more than once.
In which text can you find information about...
1 what GPs should say to patients requesting codeine?__________
2 basic indications of an opioid problem?_______
3 different medications used for weaning patients off opioids?________
4 decisions to make before beginning treatment of dependence?_______
5 defining features of a use disorder?_______
6 the development of a common goal for both prescriber and patient?_____
7 sources of further information on pain management?_______
Questions 8-14
Answer each of the questions, 8-14, with a word or short phrase from one of
the texts. Each answer may include words, numbers or both. Your answers
should be correctly spelled.
8 What will reduced doses of opioids lead to a reduction of?
___________________________________________________________
9 What is the most effective medication for tapering opioid dependence?
___________________________________________________________
10 How long should over the counter codeine analgesics be used for?
___________________________________________________________
11 When should doctors consider referring a patient to a pain expert or clinic?
___________________________________________________________
12 What might a patient give permission to before starting treatment?
___________________________________________________________
13 What might be increasingly neglected as a result of opioid use?
___________________________________________________________
14 How many Buprenorphine patches are needed to taper from codeine
tablets?
___________________________________________________________
Page 256
Questions 15-20
Complete each of the sentences, 15-20, with a word or short phrase from one
of the texts. Each answer may include words, numbers or both. Your answers
should be correctly spelled.
-- The use of Buprenorphine-naxolone requires a (15)____________ before

treatment.
-- The use of symptomatic medications for the treatment of opioid dependence

has been found to have (16) ____________ than tramadol.
-- Different definitions of opioid dependence share the same (17) ____________
-- Once it is decided that opioid taper is a suitable treatment the doctor and
patient should create a (18) ____________
-- Recent research indicates that (19) ____________ can work as well as

combination analgesics including codeine and oxycodone.
-- The ICD-10 defines a patient as dependent if they have (20) ____________

key symptoms simultaneously.
Page 257
E2 Language Reading Part B.2
1- According to the guidelines nurses must

a. advise the practice as soon as they get to the next home visit.
b. call the patient to confirm a time before they make a home visit.
c. inform fellow staff members when they return from a home visit.
Home Visit Guidelines
The nurse will complete all consultation notes in the patient’s home (unless not appropriate), prior to
beginning the next consultation. With a focus on nurse safety, the nurse will call the practice at the end of
each visit before progressing to the next home visit and will also communicate any unexpected
circumstances that may delay arrival back at the practice (more than one hour).
Calling from the patient’s home to make a review appointment with the GP is sufficient and can help
minimise time making phone calls. On return to the practice the nurse will immediately advise staff
members of their return. This time will be documented on the patient visit list, scanned and filed by
administration staf
.----------------------------------------------------------------------------------------------------------------------------------
2. In progressive horizontal evacuation
a) patients are evacuated through fire proof barriers one floor at a time.
b) patients who can't walk should not be moved until the fire is under control.
c) patients are moved to fire proof areas on the same level to safely wait for help.
Progressive horizontal evacuation
The principle of progressive horizontal evacuation is that of moving occupants from an area affected by fire
through a fire-resisting barrier to an adjoining area on the same level, designed to protect the occupants from
the immediate dangers of fire and smoke (a refuge). The occupants may remain there until the fire is dealt
with or await further assisted onward evacuation by staff to a similar adjoining area or to the nearest
stairway. Should it become necessary to evacuate an entire storey, this procedure should give sufficient time
for non-ambulant and partially ambulant patients to be evacuated vertically to a place of safety.
Page 258
3. The main purpose of the extract is to
a) provide information of the legal requirements for disposing of animal waste.

b) describe rules for proper selling and export of animal products.
c) define the meaning of animal by-products for healthcare researchers.
Proper disposal of animal waste
Animal by-products from healthcare (for example research facilities) have specific legislative requirements
for disposal and treatment. They are defined as “entire bodies or parts of animals or products of animal
origin not intended for human consumption, including ova, embryos and semen.” The Animal By-Products
Regulations are designed to prevent animal by-products from presenting a risk to animal or public health
through the transmission of disease. This aim is achieved by rules for the collection, transport, storage,
handling, processing and use or disposal of animal byproducts, and the placing on the market, export and
transit of animal by-products and certain products derived from them.
----------------------------------------------------------------------------------------------------------------------------------
4. According to the extract, what is the outcome of reusing medical equipment meant to be used once?
a) The maker will take no legal responsibility for safety.

b) Endoscopy units will save on equipment costs.
c) There is a higher incidence of cross infection.
Cleaning and disinfection of endoscopes should be undertaken by trained staff in a dedicated room.
Thorough cleaning with detergent remains the most important and first step in the process. Automated
washer/disinfectors have become an essential part of the endoscopy unit. Machines must be reliable,
effective, easy to use and should prevent atmospheric pollution by the disinfectant if an irritating agent is
used. Troughs of disinfectant should not be used unless containment or exhaust ventilated facilities are
provided.
Whenever possible, “single use” or autoclavable accessories should be used. The risk of transfer of infection
from inadequately decontaminated reusable items must be weighed against the cost. Reusing accessories
labelled for single use will transfer legal liability for the safe performance of the product from the
manufacturer to the user or his/her employers and should be avoided unless Department of Health criteria
are met.
Page 259
5. According to the extract what is the purpose of the guidelines?
a) To present statistics on the incidence of melanoma in Australia and New Zealand.

b) To support the early detection of melanoma and select the best treatments.
c) To explain the causes of melanoma in populations of Celtic origin.
Foreword
Australia and New Zealand have the highest incidence of melanoma in the world. Comprehensive, up-to-
date, evidence-based national guidelines for its management are therefore of great importance. Both
countries have populations of predominantly Celtic origin, and in the course of day-to-day life their citizens
are inevitably subjected to high levels of solar UV exposure. These two factors are considered
predominantly responsible for the very high incidence of melanoma (and other skin cancers) in the two
nations. In Australia, melanoma is the third most common cancer in men and the fourth most common in
women, with over 13, 000 new cases and over 1, 750 deaths each year.
The purpose of evidence-based clinical guidelines for the management of any medical condition is to
achieve early diagnosis whenever possible, make doctors and patients aware of the most effective treatment
options, and minimise the financial burden on the health system by documenting investigations and
therapies that are inappropriate.
----------------------------------------------------------------------------------------------------------------------------------
6. What should employees declare?
a) Every item received from one donor.

b) Each item from one donor valued at over $50.
c) Every item from one donor if the combined value is more than $50.
Reporting of Gifts and Benefits
Employees must declare all non-token gifts which they are offered, regardless of whether or not those gifts
are accepted. If multiple gifts, benefits or hospitality are received from the same donor by an employee and
the cumulative value of these is more than $50 then each individual gift, benefit or hospitality event must be
declared.
The Executive Director of Finance will be responsible for ensuring the gifts and benefits register is subject
to annual review by the Audit Committee. The review should include analysis for repetitive trends or
patterns which may cause concern and require corrective and preventive action. The Audit Committee will
receive a report at least annually on the administration and quality control of the gifts, benefits and
hospitality policy, processes and register.
Page 260
E2 Language Reading Part C.2
Extract 1
Text 1: The case for and against e-cigarettes

Electronic cigarettes first hit European and American markets in 2006 and 2007, and their popularity
has been propelled by international trends favouring smoke-free environments. Sales reportedly have
reached $650 million a year in Europe and were estimated to reach $3. 6 billion in the US in 2018.
Although research on e-cigarettes is not extensive, a picture is beginning to emerge. Surveys suggest
that the vast majority of those who use e-cigarettes treat them as smoking-cessation aides and self-report
that they have been key to quitting. Data also indicate that e-cigarettes help to reduce tobacco cigarette
consumption. A 2011 survey, based on a cohort of first-time e-cigarette purchasers, found that 66. 8
percent reported reducing the number of cigarettes they smoked per day and after six months, 31 percent
reported not smoking. These results compare favorably with nicotine replacement therapies (NRTs) like
the patch and nicotine gum. Interestingly, a randomized controlled trial found that even e-cigarettes not
containing nicotine were effective both in achieving a reduction of tobacco cigarette consumption and
longer term abstinence, suggesting that “factors such as the rituals associated with cigarette handling
and manipulation may also play an important role. ” Some tobacco control advocates worry that they
simply deliver an insufficient amount of nicotine to ultimately prove effective for cessation.
Nevertheless, the tobacco control community has embraced FDA approved treatments—NRTs, as well
as the drugs bupropion and varenicline —that have relatively low success rates. In a commentary
published in the Journal of the American Medical Association, smoking cessation experts Andrea Smith
and Simon Chapman of the University of Sydney said that smoking cessation drugs fail most of those
who try them. “Sadly, it remains the case that by far the most common outcome at 6 to 12 months after
using such medication in real world settings is continuing smoking. Few, if any, other drugs with such
records would ever be prescribed, ” they wrote.
Amongst smokers not intending to quit, e-cigarettes—both with and without nicotine—substantially
reduced consumption in a randomized controlled trial, not only resulting in decreased cigarette
consumption but also in “enduring tobacco abstinence. ” In a second study from 2013, the authors
reported that after 24 months, 12. 5 percent of smokers remained abstinent while another 27. 5 percent
reduced their tobacco cigarette consumption by 50 percent. Finally, a third study commissioned in
Australia has come to the same conclusion, though a high dropout rate (42 percent) makes these
findings questionable.
Users widely perceive e-cigarettes to be less toxic. While the FDA has found trace elements of
carcinogens, levels are comparable to those found in nicotine replacement therapies. Results from a
laboratory study released in 2013 found that that while e-cigarettes do contain contaminants, the levels
range from 9 to 450 times lower than in tobacco cigarette smoke. These are comparable with the trace
amounts of toxic or carcinogenic substances found in medicinal nicotine inhalers. A prominent anti-
tobacco advocate, Stanton Glantz, has warned of the need to protect people from secondhand emissions.
While one laboratory study indicates that passive “vaping, ” as smoking an e-cigarette is commonly
known, releases volatile organic compounds and ultrafine particles into the indoor environment, it noted
that the actual health impact is unknown and should remain a chief concern. A 2014 study concluded
that e-cigarettes are a source of second hand exposure to nicotine but not to toxins. Nevertheless,
bystanders are exposed to 10 times less nicotine exposure from e-cigarettes compared to tobacco
cigarettes.
Page 261
There are a number of interesting points of agreement among proponents and skeptics of e-cigarettes.
First, all agree that regulation to ensure the quality of e-cigarettes should be uniform. Laboratory
analyses have found sometimes wide variation across brands, in the level of carcinogens, the presence
of contaminants, and the quality of nicotine. Second, proponents and detractors of e-cigarettes tend to
agree that — considered only at the individual level—e-cigarettes are a safer alternative to tobacco
cigarette consumption. The main concern is how e-cigarettes might shape tobacco use patterns at the
population level. Proponents stress the evidence base that we have reviewed. Skeptics remain worried
that e-cigarettes will become “dual use” products. That is, smokers will use e-cigarettes, but will not
reduce their smoking or quit.
Perhaps most troubling to public health officials is that e-cigarettes will "renormalize" smoking,
subverting the cultural shift that has occurred over the past 50 years and transforming what has become
a perverse habit into a pervasive social behaviour. In other words, the fear is that e-cigarettes will allow
for re-entry of the tobacco cigarette into public view. This would unravel the gains created by smoke-
free indoor (and, in some scientifically-unwarranted instances) outdoor environments. Careful
epidemiological studies will be needed to determine whether the individual gains from e-cigarettes will
be counteracted by population-level harms. For policy makers, the challenge is how to act in the face of
uncertainty.
1. What does the writer suggest about the research into e-cigarettes?
a) Not enough research is being carried out.

b) Early conclusions are appearing from the evidence.
c) Too much of the available data is self-reported.
d) An extensive picture of e-cigarette use has emerged.
2. What explanation does the writer offer for the effect of non-nicotine e-cigarettes?
a) They deliver an insufficient volume of nicotine to help smoking cessation.

b) They compare well with patches, nicotine gum and other NRT's.
c) First time e-cigarette buyers tend to use them
d) Behavioural elements are significant in quitting smoking.
3. What is the attitude of Andrea Smith and Simon Chapman to the use of smoking cessation drugs?
a) They approve of and embrace these treatments.

b) They consider them largely unsuccessful as treatments.
c) They think they should be replaced with other treatments.
d) They believe they should never be prescribed as treatment.
Page 262
4. What problem with one of the studies is mentioned in paragraph 4?
a) The research questions the study asked.

b) The number of participants who left the study.
c) The similarity of the conclusion to other studies.
d) The study used e-cigarettes without nicotine.
5. What is "these" in paragraph 5 referring to?
a) Laboratory study results

b) Nicotine inhalers
c) Contamination levels
d) Tobacco cigarettes
6. Research mentioned in paragraph 5 suggests that
a) E-cigarettes release dangerous toxins into the air.

b) E-cigarettes should be banned from indoor environments.
c) E-cigarettes are more toxic than nicotine replacement therapies
d) cigarettes present a far greater risk of secondhand exposure to toxins
7. The word uniform in paragraph 7 suggests that e-cigarettes should
a) Be clearly regulated against.

b) Only come in one brand.
c) Be of a standard quality.
d) Contain no contaminants.
8. What do both critics and supporters of e-cigarettes agree?
a) Available research evidence must be reviewed.

b) E-cigarette use may not result in quitting.
c) Smoking tobacco is more dangerous than vaping.
d) E-cigarettes are shaping the public's tobacco use.
Page 263
Extract 2
Text 2: Vivisection
In 1875, Charles Dodgson, under his pseudonym Lewis Carroll, wrote a blistering attack on vivisection.
He sent this to the governing body of Oxford University in an attempt to prevent the establishment of a
physiology department. Today, despite the subsequent evolution of one of the most rigorous
_____
governmental regulatory systems in the world, little has changed. A report sponsored by the UK Royal
Society, “The use of non-human primates in research”, attempts to establish a sounder basis for the
debate on animal research through an in-depth analysis of the scientific arguments for research on
monkeys.
In the UK, no great apes have been used for research since 1986. Of the 3000 monkeys used in animal
research every year, 75% are for toxicology studies by the pharmaceutical industry. Although
expenditure on biomedical research has almost doubled over the past 10 years, the number of monkeys
used for this purpose (about 300) has tended to fall. The report, which mainly discusses the use of
monkeys in biomedical research, pays particular attention to the development of vaccines for AIDS,
malaria, and tuberculosis, and to the nervous system and its disorders. The report assesses the impact of
these issues on global health, together with potential approaches that might avoid the use of animals in
research. Other research areas are also discussed, together with ethics, animal welfare, drug discovery,
and toxicology.
The report concludes that in some cases there is a valid scientific argument for the use of monkeys in
medical research. However, no blanket decisions can be made because of the speed of progress in
biomedical science (particularly in molecular and cell biology) and because of the available non-
invasive methods for study of the brain. Every case must be considered individually and supported by a
fully informed assessment of the importance of the work and of alternatives to the use of animals.
Furthermore, the report asks for greater openness from medical and scientific journals about the amount
of animal suffering that occurred in studies and for regular publication of the outcomes of animal
research and toxicology studies. It calls for the development of a national strategic plan for animal
research, including the dissemination of information about alternative research methods to the use of
animals, and the creation of centres of excellence for better care of animals and for training of scientists.
Finally, it suggests some approaches towards a better-informed public debate on the future of animal
research.
Although the report was received favourably by the mass media, animal-rights groups thought that it did
not go far enough in setting priorities for development of alternatives to the use of animals. In fact, it
investigates many of these approaches, including cell and molecular biology, use of transgenic mice (an
alternative to use of primates), computer modelling, in-silico technology, stem cells, microdosing, and
pharmacometabonomic phenotyping. However, the report concludes that although many of these
techniques have great promise, they are at a stage of development that is too early for assessment of
their true potential.
The controversy of animal research continues unabated. Shortly after publication of the report, two
highly charged stories were published in the media. A study that used systematic reviews to compare
treatment outcome from clinical trials of animals with those of human beings suggested that discordance
in the results might have been due to bias, poor design, or inadequacies of animals for modelling of
human disease. Although the study made some helpful suggestions for the future, its findings are not
surprising. The imperfections of animals for study of human disease and of drug trials are documented
widely.
Page 264
The current furore about the UK Government's ban on human nuclear-transfer experiments involving
animals should not surprise us either. This area of research had a bad start when this method of
production of stem cells was labelled as therapeutic cloning, thus confusing it with reproductive cloning
- a_______
problem that, surely, licensing bodies and the scientific community should have anticipated. The
possibilities that insufficient human eggs will be available, and that insertion of human nuclei into
animal eggs might be necessary, have been discussed by the scientific community for several years, but
have been aired rarely in public, leaving much room for confusion
Biomedical science is progressing so quickly that maintenance of an adequate level of public debate on
ethical issues is difficult. Hopefully the sponsors of the recent report will now activate its
recommendations, not least how better mechanisms can be developed to broaden and sustain
interactions between science and the public. Although any form of debate will probably not satisfy the
extremists of the antivivisection movement, the rest of society deserves to receive the information it
needs to deal with these extremely difficult issues.
1. How does the writer characterise Lewis Carroll's attitude to vivisection?
a) He was in favour of clear regulations to control it.

b) He felt the Royal Society should not support it.
c) He was strongly opposed to it.
d) He supported its use in physiology.
2. The word rigorous in paragraph 1 implies that the writer thinks UK vivisection laws are
a) Strict and severe

b) Careful and thorough
c) Ambiguous and unhelpful
d) Accurate and effective
3. What is the major focus of the report mentioned in paragraph 2?
a) Animal experimentation in the pharmaceutical industry

b) Recent increases in spending on Biomedical research
c) Testing new treatments for serious disease on monkeys
d) Possible alternatives to testing new drugs on animals
Page 265
4. What is the main conclusion of the report?
a) Scientific experimentation on monkeys is justified.

b) Rapid development in biomedicine makes it hard to draw conclusions.
c) Non-invasive techniques should be preferred in most cases.
d) Research that requires monkeys should be evaluated independently.
5. What conclusion is drawn about alternative techniques to vivisection?
a) Developing alternatives should be prioritised.

b) Transgenic mice are a viable alternative to monkeys.
c) Many alternative techniques are more promising than animal testing.
d) They aren't well enough understood yet to adopt for research.
6. What does the writer claim about the use of animals in medical research?
a) The limitations of using animals in research are well understood.

b) Results from too many animal trials are biased.
c) Human studies are known to be more reliable.
d) Strong media reaction has kept up the controversy.
7. The phrase a problem in paragraph 6 refers to the
a) Government licensing of animal experiments.

b) Confusion between the names of two different methods.
c) Chortage of human embryos available for experiments.
d) Prohibition against human nuclear transfer in the UK.
8. The author thinks it is hard to keep the public adequately informed about this research because
a) The report sponsors have not activated the recommendations.

b) Of the rapid evolution of biomedical technologies.
c) Scientists don't interact with the public enough.
d) Extreme views from opponents cloud the debate.
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E2language
Test II- Answer
Answer Sheet
1) B
2) A
3) C
4) D
5) A
6) D
7) B
---------------------------------------------------------------------
8) pain intensity
9) buprenorphine-naloxone / buprenorphine - naloxone /
buprenorphine-naloxone (sublingual) / buprenorphine -
naloxone (sublingual)
10) one to three days / 1 to 3 days / 1-3 days / 1 - 3 days
11) if pain isn't managed with nonopioid medications / if
pain isn't managed / if pain isn't managed with non-
opioid medications
12) urine drug screening
13) alternative interests or pleasures / alternative
interests and pleasures / interests or pleasures / interests
and pleasures
14) a single patch / one patch / 1 patch
---------------------------------------------------------------------
15) permit
16): poorer outcomes
17) central features / features
18) treatment agreement
19) nonopioid combinations / non-opioid combinations
20) three or more / at least three / 3 or more / at least 3
Page 267
Part B2
1. C
2. C
3. A
4. A
5. B
6. C
Part C2
Answers
1. B
2. D
3. B
4. B
5. C
6. D
7. C
8. C
Answers
1. C
2. B
3. C
4. D
5. D
6. A
7. B
8. B
Page 268
12
E2language Test III
Page 269
ADHD
Text A
The GP’s role in the management of ADHD
It helps to remind patients that ADHD is not all bad. ADHD is associated with positive attributes
such as being more spontaneous and adventurous. Some studies have indicated that people
with ADHD may be better equipped for lateral thinking. It has been suggested that explorers or
entrepreneurs are more likely to have ADHD.
In addition, GPs can reinforce the importance of developing healthy sleep–wake behaviours,
obtaining adequate exercise and good nutrition. These are the building blocks on which other
treatment is based. For patients who are taking stimulant medication, it is helpful if the GP
continues to monitor their blood pressure, given that stimulant medication may cause elevation.
Once a patient has been stabilised on medication for ADHD, the psychiatrist may refer the
patient back to the GP for ongoing prescribing in line with state-based guidelines. However, in
most states and territories, the GP is not granted permission to alter the dose.
Text B

ADHD: Overview

Contrary to common belief, ADHD is not just a disorder of childhood. At least 40 to 50% of
children with ADHD will continue to meet criteria in adulthood, with ADHD affecting about one in
20 adults. ADHD can be masked by many comorbid disorders that GPs are typically good at
recognising such as depression, anxiety and substance use. In patients with underlying ADHD,
the attentional, hyperactive or organisational problems pre-date the comorbid disorders and are
not episodic as the comorbid disorders may be. GPs are encouraged to ask whether the
complaints are of recent onset or longstanding. Collateral history can be helpful for developing a
timeline of symptoms (e.g. parent or partner interview). Diagnosis of underlying ADHD in these
patients will significantly improve their treatment outcomes, general health and quality of life.
Page 270
Text C
Page 271
Text D
Treatment of ADHD
It is very important that the dosage of medication is individually optimised. An analogy may be made
with getting the right pair of glasses – you need the right prescription for your particular
presentation with not too much correction and not too little. The optimal dose typically requires
careful titration by a psychiatrist with ADHD expertise. Multiple follow-up appointments are usually
required to maximise the treatment outcome. It is essential that the benefits of treatment outweigh
any negative effects. Common side effects of stimulant medication may include:
• appetite suppression
• insomnia
• palpitations and increased heart rate
• feelings of anxiety
• dry mouth and sweating
END OF PART A
Page 272
E2language
Test III
E2 Language Reading Part A.3
 Look at the four texts, A-D, in the (printable) Text Booklet.
 For each question, 1-20, look through the texts, A-D, to find the relevant information.
 Write your answers on the spaces provided in the ANSWER SHEET.
 Answer all the questions within the 15-minute time limit.
ADHD
Questions 1-7
For each of the questions, 1-7, decide which text (A, B, C or D) the information comes from. You may
use any letter more than once.
1 different types of ADHD medication? __________
2 possible side effects of medication? ___________
3 conditions which may be present alongside ADHD? _____________
4 a doctor’s control over a patient’s medication? ____________
5 positive perspectives on having ADHD? ___________
6 when patients should take their ADHD medicine? _______________
7 figuring out a patient’s optimal dosage of medication? ________________
Page 273
Questions 8-14
include words, numbers or both. Your answers should be correctly spelled.
8 What is the maximum recommended dose of Dexamfetamine?
________________________________________________________________
9 What is typically needed to get the best results from ADHD treatment?
________________________________________________________________
10 How can GP’s collect information about their patient’s collateral history?
________________________________________________________________
11 What causes symptoms such as palpitations and anxiety in some patients?
________________________________________________________________
12 What proportion of children with ADHD will carry symptoms into adulthood?
________________________________________________________________
13 What positive personality traits are sometimes associated with ADHD?
________________________________________________________________
14 Which medication has dose recommendations related to patient weight?
________________________________________________________________
Questions 15-20
Complete each of the sentences, 15-20, with a word or short phrase from one of the texts. Each answer
may include words, numbers or both. Your answers should be correctly spelled.
Sleep, exercise and nutrition comprise the (15)_________________of further ADHD treatment.
When diagnosing ADHD, it is important to ask if the issues arose recently or are (16)
_________________
It is possible to move to (17) _________________after one month of immediate-release

methylphenidate.
Signs of ADHD can be disguised by (18) _________________ which GPs are more likely to recognise.
GPs should regularly check the (19) _________________ of patients prescribed stimulant medication.
Establishing the ideal dose of ADHD medication needs (20) _________________ by an expert
psychiatrist.
Page 274
E2 Language Reading Part B.3
1. According to the extract, to prevent the spread of infection, emergency department isolation
rooms
a) should be placed away from the main entry doors.

b) are more numerous than those of other departments.
c) ought to be situated near where people enter the unit.
DESIGN PRINCIPLES FOR ISOLATION ROOMS
The aim of environmental control in an isolation room is to control the airflow, thereby reducing the number of airborne
infectious particles that may infect others within the environment.
This is achieved by:
 controlling the quality and quantity of intake and exhaust air;

 diluting infectious particles in large volumes of air;
 maintaining differential air pressures between adjacent areas; and
 designing patterns of airflow for particular clinical purposes.
The location and design of isolation rooms within a particular department or inpatient unit should ideally enable their
separation from the rest of the unit. Multiple isolation rooms should be clustered and located away from the main entrance of
the unit. An exception is an emergency department where it is recommended that designated isolation rooms be located near
the entry to prevent spread of possible airborne infection throughout the unit.
------------------------------------------------------------------------------------------------------------------------------------------------------
2. What do staff need to be conscious of when working in Anterooms?
a) Keeping used and unused medical clothing apart.
b) Ensuring the ambient pressure in the room is a minimum 15 Pascal.
c) Keeping the door closed at all times.
ANTEROOMS
Anterooms allow staff and visitors to change into, and dispose of, personal protective equipment used on entering and
leaving rooms when caring for infectious patients. Clean and dirty workflows within this space should be considered so that
separation is possible. Anterooms increase the effectiveness of isolation rooms by minimising the potential escape of
airborne nuclei into a corridor area when the door is opened.
For Class N isolation rooms the pressure in the anteroom is lower than the adjacent ambient (corridor) pressure, and positive
with respect to the isolation room. The pressure differential between rooms should be not less than 15 Pascal.
Anterooms are provided for Class N isolation rooms in intensive care units, emergency departments, birthing units,
infectious diseases units, and for an agreed number of patient bedrooms within inpatient units accommodating patients
with respiratory conditions.
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3. What is the basic principle of flexible design?
a) Creating systems which match current policy and can adjust to other possible
guidelines.
b) Designing healthcare facilities which strictly adhere to current policy.
c) Changing healthcare policies regularly to match changes in the marketplace.
FLEXIBLE DESIGN
In healthcare, operational policies change frequently. The average cycle may be as little as five years.
This may be the result of management change, government policy, and turnover of key staff or change
in the marketplace. By contrast, major healthcare facilities are typically designed for 30 years, but may
remain in use for more than 50 years. If a major hospital is designed very tightly around the operational
policies of the day, or the opinion of a few individuals, who may leave at any time, then a significant
investment may be at risk of early obsolescence. Flexible design refers to planning models that can not
only adequately respond to contemporary operational policies but also have the inherent flexibility to
adapt to a range of alternative, proven and forward-looking policies.
-----------------------------------------------------------------------------------------------------------------------------
4. When prescribing antibiotics for a human bite, what should the medical professional remember?
a) Not all patients should be given antibiotics given the nominal infection risk.
b) The bacterium Streptococcus spp. is the most common in bite patients.
c) Eikenellacorrodens is not susceptible to several antibiotics often used for skin
infections.
Human bites
Human bite injuries comprise clenched-fist injuries, sustained when a closed fist strikes the teeth of
another person, and occlusive bites, resulting from direct closure of teeth on tissue. Clenched-fist
injuries are more common than occlusive bites, particularly in men, with most human bites occurring on
the hands. Human bites result in a greater infection and complication rate than animal bites. Cultures of
human bites are typically polymicrobial. Mixed aerobic and anaerobic organisms are common, with the
most common isolates including Streptococcus spp. and Eikenellacorrodens, which occurs in up to one-
third of isolates.
Some authors suggest that all patients with human bites should be commenced on antibiotic
prophylaxis, given the high risk of infection. The choice of antibiotic therapy should cover E. corrodens,
which is resistant to first-generation cephalosporins (such as cefalexin), flucloxacillin and clindamycin,
antibiotics that are often used for skin and soft tissue infections.
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5. The extract informs us that a model of care
a) is only implemented at certain times and places.

b) should include its own application and assessment.
c) involves the development of a project management tool.
What is a MoC?
A “Model of Care” broadly defines the way health services are delivered. It outlines best practice care
and services for a person, population group or patient cohort as they progress through the stages of a
condition, injury or event. It aims to ensure people get the right care, at the right time, by the right team
and in the right place.
When designing a new MoC, the aim is to bring about improvements in service delivery through
effecting change. As such creating a MoC must be considered as a change management process.
Development of a new MoC does not finish when the model is defined, it must also encompass
implementation and evaluation of the model and the change management needed to make that happen.
Developing a MoC is a project and as such should follow a project management methodology.
-----------------------------------------------------------------------------------------------------------------------------
6. What is the basic difference between delegation, referral, and handover?
a) How many practitioners are involved in each part of the process.

b) How much authority is attributed to each practitioner.
c) How long each of the processes take a practitioner to complete.
4.3 Delegation, referral and handover
Delegation involves one practitioner asking another person or member of staff to provide care on behalf of the
delegating practitioner while that practitioner retains overall responsibility for the care of the patient or client.
Referral involves one practitioner sending a patient or client to obtain an opinion or treatment from another
practitioner. Referral usually involves the transfer in part of responsibility for the care of the patient or client,
usually for a defined time and a particular purpose, such as care that is outside the referring practitioner’s
expertise or scope of practice.
Handover is the process of transferring all responsibility to another practitioner.
Page 277
Text 1: Personal devices and hearing loss

Most of us have experienced walking past someone and being able to hear every sound coming
from their headphones. If you’ve ever wondered whether this could be damaging their hearing, the
answer is yes. In the past, noise-induced hearing loss typically affected industrial workers, due to
prolonged exposure to excessive levels of noise with limited or non-existent protective equipment.
There are now strict limits on occupational noise exposure and many medico-legal claims have
been filed as a result of regulation. The ubiquitous use of personal music players has, however,
radically increased our recreational noise exposure, and research suggests there may be some cause
for concern.
The problem is not just limited to children and teenagers either; adults listen to loud music too.
According to the World Health Organization, hearing loss is already one of the leading causes of
disability in adults globally, and noise-induced hearing loss is its second-largest cause. In Australia,
hearing loss is a big public health issue, affecting one in six people and costing taxpayers over
A$12 billion annually for diagnosis, treatment, and rehabilitation.
When sounds enter our ear, they set in motion tiny frequency-specific hair cells within the cochlea,
our hearing organ, which initiate the neural impulses which are perceived by us as sounds.
Exposure to high levels of noise causes excessive wear and tear, leading to their damage or
destruction. The process is usually gradual and progressive; as our cochlea struggles to pick up
sounds from the damaged frequencies we begin to notice poorer hearing. Unfortunately, once the
hair cells are gone, they don’t grow back.
A number of US studies have shown the prevalence of noise-induced hearing loss in teenagers is
increasing, and reports from Australia have suggested there’s an increased prevalence of noise-
induced hearing loss in young adults who use personal music players. This is a worrying trend
considering the widespread usage of these devices. Even a slight hearing loss can negatively affect
a child’s language development and academic achievement. This is of significant concern
considering some studies have reported a 70% increased risk of hearing loss associated with use of
personal music players in primary school-aged children.
Some smartphones and personal music players can reach up to 115 decibels, which is roughly
equivalent to the sound of a chainsaw. Generally, 85 decibels and above is considered the level
where noise exposure can cause permanent damage. Listening at this level for approximately eight
hours is likely to result in permanent hearing loss. What’s more, as the volume increases, the
amount of time needed to cause permanent damage decreases. At 115 decibels, it can take less than
a minute before permanent damage is done to your hearing.
In Australia a number of hearing education campaigns, such as Cheers for Ears, are teaching
children and young adults about the damaging effects of excessive noise exposure from their
personal music players with some encouraging results. Hopefully, this will lead to more responsible
behaviour and prevent future cases of noise-induced hearing loss in young adults.
Currently, there are no maximum volume limits for the manufacturers of personal music players in
Australia. This is in stark contrast to Europe, where action has been taken after it was estimated that
50 and 100 million Europeans were at risk of noise-induced hearing loss due to personal music
Page 278
players. Since 2009, the European Union has provided guidance to limit both the output and usage
time of these devices. Considering the impact of hearing loss on individuals and its cost to society,
it’s unclear why Australia has not adopted similar guidelines. Some smartphones and music players
allow you to set your own maximum volume limits. Limiting the output to 85 decibels is a great
idea if you’re a regular user and value preserving your hearing. Taking breaks to avoid continued
noise exposure will also help reduce your risk of damaging your hearing.
Losing your hearing at any age will have a huge impact on your life, so you should do what you can to
preserve it. Hearing loss has often been referred to as a “silent epidemic”, but in this case it is definitely
avoidable.
1. The writer suggests that the risks from exposure to excessive industrial noise
a) Have become better regulated over time.

b) Have increased with the spread of new media devices.
c) Were limited or non-existent in the past.
d) Are something most people have experienced.
2. The word 'ubiquitous' in paragraph 1 suggests that use of personal media players is
a) Getting out of control.

b) Radically increasing.
c) Extremely common.
d) A serious health risk.
3. In the second paragraph, the writer aims to emphasise the
a) Impacts of hearing loss on young people.

b) Significant global effect of noise related hearing loss.
c) WHO's statistical information on hearing loss.
d) Huge cost of hearing loss treatment in Australia.
Page 279
4. What does the word 'their' in paragraph 3 refer to?
a) Smart phones and music players

b) People with hearing loss
c) Neural impulses entering our ear
d) Tiny hair cells in the ear
5. What does the research mentioned in paragraph four show?
a) A higher prevalence of personal music devices in primary schools.

b) The negative impact of device related hearing loss on academic and linguistic skills.
c) An increasing number of teens and young adults suffering noise related hearing loss.
d) The widespread trend for increased use of personal music devices.
6. In paragraph 5, the writer suggests that
a) Chainsaws and smartphones are negatively impacting the public's hearing

b) Listening to music on a smartphone will damage your hearing.
c) Smartphones are designed to play music at dangerously high volumes.
d) More rules should be in place to control how loud smartphones can go.
e)
7. Why does the writer mention the Australian education programs in paragraph 6?
a) To encourage schools to adopt the Cheers for Ears program.

b) To suggest that education could lead to safer behaviour in young people
c) To criticise governments for not educating youths on the danger of excessive noise.
d) To highlight a successful solution to the issue of hearing loss in young people.
8. What is the writer's attitude to the lack of manufacturing guidelines for music devices in
Australia?
a) There is no clear reason why Australia has not created guidelines.

b) The implementation of guidelines in Australia is unnecessary.
c) Guidelines probably won't be created in Australia.
d) It will be difficult to create guidelines in Australia.
Page 280
Text 2: What is herd immunity?
A recent outbreak of chickenpox is a reminder that even in countries where immunisation rates are high,
children and adults are still at risk of vaccine-preventable diseases. Outbreaks occur from time to time
for two main reasons. The first is that vaccines don’t always provide complete protection against
disease and, over time, vaccine protection tends to diminish. The second is that not everyone in the
population is vaccinated. This can be for medical reasons, by choice, or because of difficulty accessing
medical services. When enough unprotected people come together, infections can spread rapidly. This is
particularly the case in settings such as schools where large numbers of children spend long periods of
time together.
When a high proportion of a community is immune it becomes hard for diseases to spread from person
to person. This phenomenon is known as herd immunity. Herd immunity protects people indirectly by
reducing their chances of coming into contact with an infection. By decreasing the number of people
who are susceptible to infection, vaccination can starve an infectious disease outbreak in the same way
that firebreaks can starve a bushfire: by reducing the fuel it needs to keep spreading. If the immune
proportion is high enough, outbreaks can be prevented and a disease can even be eliminated from the
local environment. Protection of “the herd” is achieved when immunity reaches a value known as the
“critical vaccination threshold”. This value varies from disease to disease and takes into account how
contagious a disease is and how effective the vaccine against it is.
For a disease outbreak to “grow”, each infected person needs to pass their disease on to more than one
other person, in the same way that we think about population growth more generally. If individuals
manage only to “reproduce” themselves once in the infectious process, a full-blown outbreak won’t
occur. For example, on average someone with influenza infects up to two of the people they come into
contact with. If one of those individuals was already fully protected by vaccination, then only one of
them could catch the flu. By immunising half of the population, we could stop flu in its tracks.
On the other hand, a person with chickenpox might infect five to ten people if everyone were
susceptible. This effectively means that we need to vaccinate around nine out of every ten people (90%
of the population) to prevent outbreaks from occurring. As mentioned earlier, vaccines vary in their
ability to prevent infection completely, particularly with the passing of time. Many vaccines require
several “booster” doses for this reason. When vaccine protection is not guaranteed, the number of
people who need to be vaccinated to achieve herd immunity and prevent an outbreak is higher.
Chickenpox vaccine is one such example: infections can occur in people who have been vaccinated.
However, such cases are typically less severe than in unimmunised children, with fewer spots and a
milder symptom course.
In Australia, overall vaccine coverage rates are high enough to control the spread of many infectious
diseases. Coverage shows considerable geographic variation, though, with some communities recording
vaccination levels of less than 85%. In these communities, the conditions necessary for herd immunity
may not be met. That means localised outbreaks are possible among the unvaccinated and those for
whom vaccination did not provide full protection. In the Netherlands, for example, high national
measles vaccine uptake was not enough to prevent a very large measles outbreak (more than 2, 600
cases) in orthodox Protestant communities opposed to vaccination.
Australia’s National Immunisation Strategy specifically focuses on achieving high vaccine uptake
within small geographic areas, rather than just focusing on a national average. Although uptake of
chickenpox vaccine in Australia was lower than other infant vaccines, coverage is now comparable.
Media attention has emphasised those who choose not to vaccinate their children due to perceived risks
associated with vaccination. However, while the number of registered conscientious objectors to
vaccination has increased slightly over time, these account for only a small fraction of children. A
recent study found only 16% of incompletely immunised children had a mother who disagreed with
Page 281
vaccination. Other factors associated with under vaccination included low levels of social contact, large
family size and not using formal childcare.
Tailoring services to meet the needs of all parents requires a better understanding of how families use
health services, and of the barriers that prevent them from immunising. To ensure herd immunity can
help protect all children from preventable disease, it’s vital to maintain community confidence in
vaccination. It’s equally important the other barriers that prevent children from being vaccinated are
identified, understood and addressed.
1. According to the writer what causes occasional outbreaks of preventable diseases?
a) A high prevalence of disease.

b) Limited access to vaccination.
c) A low prevalence of vaccination.
d) Attitudes towards vaccination.
e)
2. Why does the writer mention bushfires in paragraph 2?
a) To emphasise the effectiveness of herd immunity.

b) To describe a method for eliminating disease.
c) To warn of the risks of of vaccination.
d) To highlight the severity of the flu.
e)
3. The phrase "stop flu in its tracks" in paragraph 3 refers to the
a) Prevention of flu spreading.

b) Eradication of the flu virus.
c) Minimisation of flu victims.
d) Reduction in severity of flu symptoms
e)
4. Information in paragraph 4 implies that
a) The chickenpox vaccine is highly unreliable.

b) Chickenpox is more contagious than the flu.
c) Booster vaccines should be given in schools.
d) Outbreaks of chickenpox are on the rise.
Page 282
5. In paragraph 5, the writer emphasises the importance of
a) How geographical variation contributes to outbreaks.

b) Differences in global vaccination guidelines.
c) The influence of religious beliefs on vaccination.
d) Enforcing high vaccine coverage rates.
6. Why does the writer mention Australia's National Immunisation Strategy?
a) To serve as a counter argument.

b) To engage Australian readers.
c) To reinforce a previous point.
d) To introduce a new topic.
7. The research quoted in paragraph 7 reinforces that
a) The media presents vaccination negatively.

b) Many factors contribute to under vaccination.
c) Parental objections account for most unvaccinated children.
d) The number of conscientious objectors has increased over time.
8. In the final paragraph, the writer focuses on
a) The importance of widespread faith in vaccination.

b) The difficulty of tailoring health services to all parents.
c) The identification of barriers to overcoming under vaccination.
d) The different kinds of preventable disease that need to be overcome.
Page 283
E2language
Test III- Answer
Answer Sheet
1) C
2) D
3) B
4) A
5) A
6) C
7) D
---------------------------------------------------------------------
8) 60 mg/day
9) multiple follow-up appointments / multiple follow up
appointments / follow up appointments
10) parent or partner interview / partner or parent
interview
11) side effects of stimulant medication / stimulant
medication
12) at least 40-50% / at least 40 - 50% / at least 40 to 50
percent / 40-50% / 40 to 50% / 40 - 50%
13) being more spontaneous and adventurous /
spontaneous and adventurous
14) atomoxetine
---------------------------------------------------------------------
15) building blocks
16): longstanding / underlying
17) longer-acting formulations of methylphenidate /
longer acting formulations of methylphenidate / longer-
acting formulations / longer acting formulations
18) comorbid disorders
19) blood pressure
20) careful titration / titration
Page 284
Part B.3
1. C
2. A
3. A
4. C
5. B
6. B
Part C.3
1. A
2. C
3. D
4. D
5. C
6. C
7. B
8. A
1. C
2. B
3. A
4. B
5. A
6. C
7. B
8. C
Page 285
13
E2language Test IV
Page 286
Evaluating Cognitive Function
Text A
Terminology
Cognitive difficulties
Cognitive changes are normal for almost all people as they age, and assessment
should focus on differentiating the normal changes of ageing from abnormal
cognitive functioning. While concerns about memory are common in older patients,
when patients complain of memory problems, they could be referring to difficulties in
a number of possible cognitive domains. Although learning and memory is often the
most salient of these domains, the problems could also be in:
● attention (ability to sustain or shift focus),
● language (naming, producing words, comprehension, grammar or syntax),
● perceptual and motor skills (construction, visual perception),
● executive function (decision making, mental flexibility), or
● social cognition.
It is thus often more appropriate to refer to cognitive rather than memory complaints
or deficits.
Text B
Pharmacological treatments
There are currently no evidence-based recommendations on medications to treat mild
cognitive impairment (MCI). If dementia is suspected then specialist referral is recommended
for confirmation of the diagnosis. If Alzheimer’s disease is confirmed then pharmacological
treatment can be considered (e.g. acetylcholinesterase inhibitors such as donepezil,
galantamine or rivastigmine).
A psychiatric or psychogeriatric referral should be considered for:

● patients who do not respond to first- or second-line treatment
● patients with atypical mental health presentations
● patients with significant psychiatric histories, including complicated depression and/or
anxiety or comorbid severe mental illnesses such as schizophrenia and bipolar affective
disorder.
Follow up
If the diagnosis remains unclear after a detailed assessment then provide general advice
and watchfully wait. All patients should have a cognitive review with a screening instrument
every 12 months, or sooner if deterioration is detected by the patient or their family.
Risk factors for progression of MCI to dementia include older age, less education, stroke,
diabetes and hypertension. Patients who are younger, more educated with higher baseline
cognitive function and no amnesia symptoms are more likely to revert from MCI to normal
cognition. Even after 10 years, between 40 and 70% of patients with MCI may not have
developed dementia.
Page 287
Text C
Domain Examples of Warning signs and questions
skills
Learning Short-term Have you noticed that you have been talking
and recall to someone and soon after forget the
memory Semantic and conversation?
autobiographical Have you had difficulty remembering the
Long-term names of people you have just met?
memory Have you had trouble keeping track of dates
Implicit learning and appointments?
Have you had any difficulty remembering
events from your past?
Have you had difficulty doing activities
previously thought as automatic, like driving
or typing?
[To informant] Has he or she been repeating
him or herself lately?
Language Object naming Have you noticed any word-finding
Word finding difficulties?
Receptive [To informant] Has he or she had more
language difficulty understanding you lately?
Executive Planning Have you had more difficulty managing your
function Decision making finances lately?
Working [To informant] Have you noticed difficulties
memory with his or her capacity to plan activities or
Flexibility make decisions?
Perceptual Visual Have you had trouble using day-to-day

motor perception objects, such as phone or cutlery?
function Perceptual- Have there been new driving difficulties such
motor Co- as staying in the lane?
ordination
Complex Sustained Are you having difficulty following what’s
attention attention going on around you?
Selective [To informant] Have you noticed that he or
attention she is more easily distracted?
Social Recognition of [To informant] Has he or she been behaving
Cognition emotions inappropriately in social situations?
Appropriateness Is he or she able to recognise social cues? Is
of behaviour to she or she able to motivate him or herself?
social norms
Page 288
Text D
Dementia, now also referred to as ‘major neurocognitive disorder’ in

the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), is defined by the
presence of substantial cognitive decline from a previous level of functioning to
the degree that the individual’s ability to live independently is compromised
owing to the cognitive deficits. Dementia is a syndrome with many possible
causes, with Alzheimer’s disease being the most common in older people. It is
generally of gradual onset with a chronic course, although there are exceptions.
Dementia must be distinguished from delirium (acute confusional state), which by
definition is of acute or recent onset and associated with loss of awareness of
surroundings, a global disturbance in cognition, changes in perception and the
sleep–wake cycle, and other features.
END OF PART A
Page 289
E2LANGUAGE
Test IV
PART A
Look at the four texts, A-D, in the (printable) Text Booklet.
For each question, 1-20, look through the texts, A-D, to find the relevant
information.
Write your answers on the spaces provided in the Question Paper.
Evaluating Cognitive Function: Questions
Questions 1-7
For each of the questions, 1-7, decide which text (A, B, C or D) the information comes
from. You may use any letter more than once.
1 what to ask patients when evaluating cognitive functioning?
2 possible choices for pharmaceutical treatments?
3 the best way to describe patient symptoms?
4 the defining features of dementia?
5 the proper focus of cognitive assessment?
6 different types of mental processing?
7 what to do when a diagnosis is remains uncertain?
Page 290
Questions 8-14
Answer each of the questions, 8-14, with a word or short phrase from one of the
texts. Each answer may include words, numbers or both. Your answers should be
correctly spelled.
8 What is the other name for dementia?
9 What is the most common cause of dementia in older people?
10 Which domain of cognition is the skill of planning associated with?
11 What is the most appropriate way to confirm a diagnosis of dementia?
12 What is recommended for patients when standard treatments are unsuccessful?
13 What is often the most noticeable of the many cognitive domains?
14 How often should a patient be cognitively screened if they are not getting worse?
Page 291
Questions 15-20
Complete each of the sentences, 15-20, with a word or short phrase from one of the
correctly spelled.
Dementia differs in important ways from (15)
, which, for example, has a sudden onset.
The DSM-5 defines dementia as substantial cognitive decline that compromises the
individual’s (16) .
There are (17) medications for MCI that
are recommended based on available research.
Many symptoms described as problems with memory are probably better
described as (18) complaints.
Social cognition includes the ability to follow accepted social rules and the (19)
To assess perceptual motor functioning doctors can ask if patients have had
difficulty using (20) objects like knives and
forks.
Page 292
PART B
Question 1
The purpose of this memo is to
A. provide staff information on appropriate methods.
B. notify staff of a possible change in standard procedure.
C. remind staff of the importance of following best practice.
Memo to: Department physicians and clinical staff

Subject: Aseptic technique
Aseptic technique protects patients during invasive clinical procedures by

employing infection control measures that minimise, as far as practicably possible,
the presence of pathogenic organisms. Good aseptic technique procedures help
prevent and control healthcare associated infections and must be preserved. As
you are aware, the aim of every procedure should be to maintain asepsis at all
times by protecting the key parts and key sites from contact contamination by
microorganisms. This can be achieved through correct hand hygiene, a non-touch
technique, glove use and ensuring asepsis and sterility of equipment. While the
principles of aseptic technique remain constant for all procedures, the level of
practice will change depending upon a standard risk assessment.
Page 293
Question 2
The guidelines require those administering thrombolysis to
A. explore other options before proceeding.
B. contact the coronary care unit prior to transfer.
C. ensure support staff are readily available.
6.2 Thrombolysis for STEMI patients

Primary percutaneous coronary intervention (PCI) is the treatment of choice for
patients presenting with an acute ST Elevation Myocardial Infarction (STEMI).
However, if it is not possible to transfer the patient to the cardiac catheter
laboratory immediately, for whatever reason, then the need for thrombolysis to be
given should be considered. The admitting team must ask the primary PCI
operator if they are able to achieve the arrival in hospital to first balloon inflation
target of 120 minutes. If not, then thrombolysis will be given on the advice of the
primary PCI operator without delay. Support for this may be given by Coronary
Care Unit (CCU) staff/Chest Pain Nurses depending on the patient’s location.
Transfer the patient with resuscitation equipment to CCU immediately after
thrombolysis is administered.
Page 294
Question 3
The guidelines specify that those performing an MRI on patients with implants or
foreign bodies
A. should abandon the scan if unsure of the device.
B. have the final say in whether to scan a patient.

use a lower field strength for conditional items.
C.
Guidelines for the management of

implants and foreign bodies during MRI
scans
Implantable devices or other foreign bodies may contraindicate MRI scanning
and/or cause significant image artefacts. There is a growing number of medical
devices and implants that are classified as ‘MRI conditional’, placing the
responsibility for safety on the operator. It should be stressed that safety at a
defined field strength or for a specific MRI system is no guarantee of safety at a
higher (or lower) field strength, or a different MRI system at the same field strength.
If there is any doubt as to the nature of a device then a scan should only proceed
after a careful assessment of the potential risks and benefits of the scan with the
device in situ. The MRI Safety Expert can assist with identifying and quantifying the
risks, but the decision to scan is a clinical one.
Page 295
Question 4
The manual informs us that the AP14 syringe pump
A. should be disconnected in times of power outage.
B. facilitates easy cleaning by its smooth exterior.
C. has a unique patient transportation feature.
Manual extract: Operation of AP14 Manual

Syringe Pump
Pump Application
The AP 14 syringe pump is simple to operate, reliable and is of general application. It
is suitable for various types of single-use syringes. BOLUS function enables quick
and repeated delivery of bolus doses to the patient, with accurately established
volume and within a specified infusion time. The pump can operate without
connection to the mains, as it is automatically supplied by the internal battery in
cases, e. g. of mains failure. It also enables to continue the infusion when the
patient is being transported from one area of the hospital to another. Simple
casing, without any parts protruding from the front panel, facilitates maintenance
and disinfection.
Page 296
Question 5
The notice on indwelling urinary catheters provides information about
A. the order for correct insertion.
B. optimal positioning of the patient.
C. how best to avoid harming patients.
Indwelling urinary catheters

Urethral, prostate or bladder neck injury resulting in false tracts, strictures and
bleeding are related to traumatic urethral insertion. Traumatic injury is less likely to
occur with appropriate catheter selection, lubrication, correct patient positioning
and insertion into a full bladder. Retention balloons should only be inflated inside
the bladder, which is indicated by urine return with IUC inserted to the hilt. If there is
any uncertainty regarding catheter placement, the balloon should not be inflated.
If the patient experiences pain with inflation, deflate the balloon immediately and
reassess IUC position as this may indicate the catheter is outside the bladder. IUCs
should be used with caution in patients at risk of self-extraction, such as those with
dementia or who are delirious. When available, ultrasonography is recommended
to evaluate bladder volumes and guide SPC insertions.
Page 297
Question 6
This extract from a handbook says that patients with delirium experience
A. a similar cognitive decline as with dementia.
B. a loss of interest during conversations.
C. influences that may trigger the disorder.
Delirium is an acute deterioration in cognition, often with altered arousal

(drowsiness, stupor, or hyperactivity) and psychotic features (e.g. paranoia). The
main cognitive deficit in delirium is ‘inattention’, e.g. the patient is distractible,
cannot consistently follow commands, and loses the thread during a verbal
exchange. Delirium and dementia commonly co-exist, however, with the latter
there is a much slower deterioration in thinking, perceiving and understanding, and
inattention is much less prominent. Because delirium is usually due to an
interaction between multiple predisposing and precipitating factors, management
should be aimed at not just finding and treating the assumed cause, but also
optimising all aspects of care.
Page 298
Text 1: Shedding Light on Complex
Regional Pain Syndrome (CRPS)
Eleven years ago, Debbie had a routine bunion operation that changed her life. Instead of
finding relief, her pain grew worse, until it was excruciating and constant. “I became
disabled and had to stop working. My foot is permanently in an air cast and I walk with a
cane. Most of the time the pain is a 10 out of 10,” she says. Debbie’s surgeon sent her to a
pain specialist, who recommended a psychiatrist. “I knew the pain wasn’t in my head,” she
says, but the medical community didn’t believe her. It wasn’t until she met neurologist
Anne Louise Oaklander that she finally received a diagnosis: Complex Regional Pain
Syndrome, or CRPS.
CRPS is a chronic pain condition that develops following trauma to a limb, such as surgery
or a fracture. As Debbie learned, “this is a very controversial condition that not a lot of
doctors understand,” says Oaklander. “Historically, the field of medicine has been very
sceptical of patients with CRPS. On top of their illness, patients have had to navigate a
medical system that is suspicious of them and hasn’t had effective treatment to offer. It adds insult
to injury.” But those who treat CRPS are hopeful the tide is turning. Recent attempts to better
_____________
comprehend CRPS have produced consensus guidelines for which patient outcomes should be
included in future research, as well as internationally agreed-upon diagnostic criteria. Investigators
are also learning more about the causes of CRPS from laboratory studies.
CRPS starts off with a surprising amount of pain that doesn’t match the initial trauma. In the first
few months, instead of the expected healing, patients describe an increase in pain levels. They
often report that a cast on the affected limb feels excessively tight and the sensation that the limb
might “explode,” says Candy McCabe, a CRPS clinician and researcher at the University of the
West of England, Bristol, UK. The limb often swells, changes colour to red or purple, and is
perceived by the patient as either very cold or very hot. Changes in hair and nail growth, and
sweating are also common. Research from Oaklander’s lab has identified persistent problems with
certain neurons in patients’ injured limbs. These nerve cells carry pain messages, but also control
the small blood vessels and sweat glands, explaining why patients have a constellation of
symptoms in addition to chronic nerve pain.
Many patients report that within a few days or weeks the limb feels completely alien, and of a very
different size and shape than it really is. Many also describe very negative feelings toward the limb
and a strong desire to have it amputated. “In CRPS, the brain’s perception of the limb changes
pretty quickly,” McCabe says. The good news is that, while in some cases CRPS becomes
persistent, about 75% of people get better without intervention, by six months to a year. “Getting a
CRPS diagnosis does not necessarily equate to a lifetime of disability,” she emphasises.
While the features mentioned above describe the “average” CRPS patient, not everyone
experiences the disease in the same way. Beyond differences in the length and severity of the
syndrome, different patients report different symptoms as the most prominent and bothersome. For
some, movement problems cause the most difficulty, while for others, the pain they experience may
___________
take centre stage. “The presentation of CRPS is variable within a common picture, but
unfortunately we don’t yet know why these different scenarios happen,” says McCabe.
Page 299
As reflected in the original name for CRPS, Reflex Sympathetic Dystrophy, one of the earliest ideas
about the biological underpinnings of the condition is the presence of dysfunction of the
sympathetic nervous system, the network of neurons that governs the body’s automatic “fight
or flight” response. Currently, researchers believe that such alterations are important in
the initial generation and acute phase of CRPS. For example, studies suggest that in the
tibial fracture model, sympathetic neurons release an immune system protein called
interleukin-6 that stimulates inflammation and pain. Andreas Goebel, a clinician and pain
researcher at the University of Liverpool, UK has identified a number of autoantibodies,
which are immune system proteins directed against a person’s own tissues or organs, in
the blood of people with chronic CRPS.
The first CRPS trial is underway, to evaluate the efficacy and safety of neridronate, a new
bisphosphonate, which is a class of drugs already widely used to prevent and treat
osteoporosis. This is a placebo- controlled clinical trial and has completed enrolment of
230 patients at 59 sites in the US and Europe. Debbie is one of the trial participants, and
has received several intravenous infusions. Neither she nor Oaklander are aware as yet if
she received neridronate or a placebo. “If this trial finds neridronate to be safe and
effective and receives approval to be marketed for CRPS, it will be historic”, says Oaklander.
“It’s only when there’s an approved drug that there’s advertising, which increases public
awareness, and spurs doctors to learn more,” she adds. “I felt it was important to participate in
this trial because it makes a statement to the world that CRPS is a real medical disease that
deserves high quality trials. This could be a landmark trial.”
Page 300
7. In the first paragraph, the writer uses Debbie’s case to convey
A. The dangers of having even minor surgery

B. A lack of awareness of CRPS among the medical fraternity.
C. The psychological causes of pain experienced by CRPS sufferers.
D. That specialist attention is warranted in such instances
8. What is meant by the phrase the tide is turning in the second paragraph?
A. Doctors now believe in the existence of CRPS.
B. Beneficial treatment is now more readily available.

C. Recent investigations are indicating a cure is in sight.
D. The medical community’s understanding is beginning to shift.
9. Evidence mentioned in the third paragraph has revealed
A. Possible reasons for the multitude of symptoms experienced.

B. Better post-operative care of limbs is needed.
C. Temperature patterns remain consistent throughout cases.
D. Further research is required into the possible causes of pain.
10. What do we learn about CRPS in the fourth paragraph?
A.Patients respond very differently to available treatment.

B. Professional diagnosis is necessary to see improvements.
C. Profound psychological impacts are often reported.
D. Amputation should only be performed when all else has failed.
Page 301
11. In the fifth paragraph, what point is made about the symptoms of CRPS?
A. The length and severity of CRPS are quite consistent.

B. Pain is the dominant symptom for CRPS sufferers.
C. CRPS presents itself in a diverse number of ways.
D. The average CRPS patient is very well understood.
12. What point is made about the sympathetic nervous system in the sixth paragraph?
A. It only affects CRPS in the very early stages.

B. It causes CRPS following a fractured tibia.
C. It has a critical role from the outset of CRPS.
D. It has less influence on CRPS than initially believed.
13. Anne Louise Oaklander values the trials highly because
A. Of the inclusion of the recently created neridronate.

B. They may help validate the authenticity of CRPS.
C. She gets to be a part of ground-breaking research.
D. It is the first time a cohort of this size has been used.
14. The final paragraph mentions that confirmation has yet to be received regarding
A. Whether Debbie was given the neridronate infusion.

B. The final number of participant enrolments for the trial.
C. Having the backing of the entire medical community.
D. The approval for public advertising campaigns.
Page 302
Text 2:
Antibiotic Resistance now a global
threat to public health
In 1945, Alexander Fleming, the man who discovered the first antibiotic said in his
Nobel Prize acceptance speech, “The time may come when penicillin can be
bought by anyone in the shops. Then there is the danger that the ignorant may
easily under dose themselves and by exposing their microbes to non- lethal
quantities of the drug, making them resistant." A recent report from the Centres
for Disease Control and Prevention (CDC) revealed that more than 2 million
people in the US alone become ill every year as a result of antibiotic-resistant
infections, and 23,000 die from such infections.
The World Health Organization (WHO) has recently published their first global report on
the issue, looking at data from 114 countries. WHO focused on determining the rate of
antibiotic resistance to seven bacteria responsible for many common infections,
including pneumonia, diarrhoea, urinary tract infections, gonorrhoea and sepsis. Their
findings were worrying. The report revealed that resistance to common
bacteria has reached "alarming" levels in many parts of the world, with some areas already out
of treatment options for common infections. For example, they found resistance to carbapenem
antibiotics used to tackle Klebsiella pneumoniae - the bacteria responsible for hospital-
acquired infections such as pneumonia and infections in newborns - has spread to all parts of
the globe.
Dr Keiji Fukuda, WHO's assistant director-general for health security, said of the report's
findings: "Effective antibiotics have been one of the pillars of recent generations, and unless we
______________
take significant actions to improve efforts to prevent infections and also change how we
produce, prescribe and use antibiotics, the world will lose more and more of these global public
health goods that allow us to live longer, healthier lives, and the implications will be
devastating. We’re heading for a post-antibiotic era effectively wiping out what is a marvel of
modern medicine."
Bacteria have shown the ability to become resistant to an antibiotic with great speed. “It’s true
that they’ve saved millions of lives over the years, and there’s also undoubtedly a growing
worldwide need. But their use at any time in any setting puts biological pressure on bacteria
that promotes the development of resistance. That’s where the blame lies, and only the medical
officer assumes this responsibility," says Dr Steve Solomon, Director of the CDC's Office of
Antimicrobial Resistance. “When antibiotics are needed to prevent or treat disease, they should
always be used. But research has shown that as much as 50% of the time, antibiotics are
prescribed when they’re not needed or they’re dispensed incorrectly, such as when a patient is
given the wrong dose. Whether it's a lack of experience or knowledge, or just the easier option,
I really can’t say.”
Page 303
Dr Charles Penn, coordinator of antimicrobial resistance at WHO, takes a slightly different
viewpoint from his peers. "One of many reasons why antibiotic use is so high is that there is a poor
understanding of the differences between bacteria, viruses and other pathogens, and also of the
value of antibiotics," he said. "Too many antibiotics are prescribed for viral infections such as
colds, flu and diarrhoea.
Unfortunately, these public misconceptions are often perpetuated by marketing and

advertising campaigns through the use of generic terms such as 'germs' and 'bugs.'
It’s difficult to try and narrow down the blame to a single origin.”
Dr Penn noted that reliance on antibiotics for modern medical benefits has
contributed to drug resistance. "Surgery, cancer treatment, intensive care, transplant
surgery, even simple wound management would all become much riskier, more
difficult options if we could not use antibiotics to prevent infection, or treat infections if they
occurred," he said. "Similarly, we now take it for granted that many infections are treatable
with antibiotics, such as tonsillitis, gonorrhoea and bacterial pneumonia. But some of these
are now becoming untreatable." Add to this the excessive and incorrect use of antibiotics in
food-producing animals since resistant bacteria can be transmitted to humans through the
food we eat, and you literally have a recipe for disaster.
Dr Penn goes on to say, "Although many warnings about resistance were issued, physicians,
that is to say prescribers, became somewhat complacent about preserving the effectiveness
of antibiotics - new drugs always seemed to be available. However, the pipeline for discovery
of new antibiotics has diminished in the past 30 years and has now run dry.” He noted,
however, that health care providers have now started to become more vigilant in prescribing
antibiotics. "Greater awareness of the urgency of the problem has given new impetus to
careful stewardship of existing antibiotics. Medical practitioners are now_________________
heeding the warning
that the pioneer of the antibiotic gave all those years ago."
Page 304
15. The writer quotes Alexander Fleming in the first paragraph to
A. Emphasise the impressive history of antibiotics.

B. Reveal the ease at which people may purchase antibiotics.
C. Compare current usage of medication to an earlier time.
D. Show that his prediction of antibiotic resistance was accurate.
16. In the second paragraph, what does the writer find particularly worrisome?
A.One particular antibiotic no longer provides resistance anywhere

B. New borns are quickly becoming resistant to all antibiotics
C. Resistance is at an all-time low for the most common infections
D. Although treatment is available globally it is largely ineffective
17. What is meant by one of the pillars in the third paragraph?
A. An innovation that changed the healthcare industry

B. A permanent fixture in the field of medicine
C. An essential component of the medical system
D. A remedy that is among the greatest inventions
18. According to Dr Steve Solomon, what is ultimately responsible for antibiotic resistance?
A. Their everyday use for common diseases

B. The prescriber’s lack of experience
C. The increase in global demand
D. The medical professional’s misuse
Page 305
19. In the fifth paragraph, Dr Charles Penn argues that when it comes to antibiotic resistance
A. Increasing their cost would deter overuse

B. The general public should be held responsible
C. Mass media plays a crucial role in its demand
D. More understanding is needed to overcome it
20. In the sixth paragraph, Dr Penn gives examples of our dependence on

antibiotics to
A. Stress that substitute medications are needed.

B. Justify the need to change our habits.
C. Show that it’s too late to reverse the damage.
D. Highlight our lack of appreciation for current treatments.
21. In the final paragraph, Dr Penn makes the point that medical practitioners
A. Have depleted the supply of antibiotics through overuse.

B. Were reluctant to take advice regarding antibiotics.
C. Once believed there was an endless supply of antibiotics.
D. Are yet to understand the damage caused by their actions.
22. In the final paragraph, the phrase heeding the warning refers to
A. Prescribers being attentive to the problem.

B. Doctors now issuing warnings to patients.
C. The medical community regretting their carelessness.
D. Practitioners looking ahead to a brighter future.
Page 306
E2language Reading
Test IV- Answer
1. C
2. B
3. A
4. D
5. A
6. C
7. B
8. major neurocognitive disorder
9. Alzheimer’s disease
10. executive function
11. specialist referral
12. psychiatric or psychogeriatric referral / psychogeriatric referral / psychiatric

referral / Psychiatric or psychogeriatric referral / Psychogeriatric referral /
Psychiatric referral
13. learning and memory
14. every 12 months / once a year / once per year
15. delirium
16. ability to live independently
17. no / zero / 0
18. cognitive
19. recognition of emotions
20. Day to day
Page 307
Part
PartBB
1- C
2- A
3- B
4- B
5- C
6- C
Part
PartBBC
Part
C.1 7- B
8- D
9- A
10-C
11-C
12-C
13- B
14- A
_________________________________________________
C.2 15- D
16- A
17- C
18- D
19- C
20- B
21- C
22- A
Page 308
14
E2language Test V
Page 309
Transfusion Reaction
Text A
INVESTIGATING ACUTE TRANFUSION REACTIONS
1. Immediately report all acute transfusion reactions with the exceptions of mild hypersensitivity
and non-haemolytic febrile transfusion reactions, to the appropriate departments.
2. Record the following information on the patient’s notes:
• Type of transfusion reaction
• Length of time after the start of the transfusion and when the reaction occurred
• Volume, type and pack numbers of the blood components transfused
3. Take the samples and send them to the appropriate laboratory
• Immediate post-transfusion blood samples from a vein in the opposite arm:
- Group & Antibody Screen
- Direct Antiglobulin Test
- Blood unit and giving set should contain residues of the transfused donor blood
4. Take the following samples and send them to the Haematology/ Clinical Chemistry Laboratory
for: • Full blood count • Urea
• Coagulation screen • Creatinine
• Electrolytes • Blood culture in an appropriate blood culture bottle
5. Complete a transfusion reaction report form.
6. Record the results of the investigations in the patient’s records for future follow-up, if required.
Text B
RELEVANT EFFECTS DRUGS & DOSES NOTES
Name Route & Dosage
st
Oxygen 60-100% 1 line
st
Bronchodilator Adrenaline 500 micrograms im 1 line
vasopressor repeated after 5 mins
if no better, or worse
st
Expand blood volume 0.9% - Saline, If patient hypotensive, 1 line
Gelufusine 20ml/kg over 5
minutes
nd
Reduce fever and Paracetamol Oral or rectal 2 line
inflammatory 10mg/kg Avoid aspirin
response containing products if
patient has low
platelet count
nd
Inhibits histamine Chlorphenamine IV 0.1 mg/kg 2 line
mediated responses (Chlorpheniramine)
nd
Inhibits immune Salbutamol By 5ml nebuliser 2 line
mediated
bronchospasm Aminophylline Use under expert
guidance
Vasopressor Adrenaline 6mg in 5-10ml/hr Use only under expert
bronchodilator 100ml guidance
5% dextrose (6%)
Page 310
Text C
Guidelines for recognition and management of acute transfusion reactions
Text D
Immediate Reaction - Life Threatening Situations
 Maintain airway and give high concentration oxygen by mask
 STOP the transfusion. Replace the giving set and keep the IV line open
 Manage as anaphylaxis protocol and ensure help is coming: stridor, wheeze and
hypotension require treatment with oxygen and adrenaline. Critical Care admission.
 Notify consultant haematologist and Hospital Transfusion Laboratory immediately.
 Send the blood unit with the giving set, freshly collected blood samples with appropriate
request form to the Hospital Transfusion Laboratory for investigations.
 Check a fresh urine sample visually for signs of haemoglobinuria.
 Commence urine collection (24 hours) and record all intake and output. Maintain fluid
balance.
 Assess for bleeding from puncture sites or wounds.
 Reassess: 1. treat bronchospasm and shock as per protocol. 2. Acute renal failure or
hyperkalaemia may require urgent renal replacement therapy.
Page 311
E2LANGUAGE
Test V
Part A
Transfusion Reaction: Questions
Questions 1-7
For each of the questions, 1-7, decide which text (A, B, C or D) the information comes
from. You may use any letter more than once.
1 the correct route for the administration of chlorphenamine?
2 the likely cause of rigors and fever?
3 the best way to describe patient symptoms?
4 initial steps to take when treating a critically ill patient?
5 the various symptoms of patients who have had a transfusion reaction?
6 where to document the findings of the appropriate investigations?
7 the effects of various medications for managing patient’s symptoms?
Page 312
Questions 8-13
Answer each of the questions, 8-13, with a word or short phrase from one of the
correctly spelled.
8 For how long should a patient’s urine be collected and documented?
9 What should be used to appropriately transport a blood culture?
10 How long should 0.9% saline be given if the patient is hypotensive?
11 What type of admission is warranted for a patient experiencing stridor?
12 What might a category 3 patient show more than a twenty percent drop in?
13 What is best avoided if the patient has a low platelet count?
Page 313
Questions 14-20
Complete each of the sentences, 14-20, with a word or short phrase from one of the
correctly spelled.
14 A vein from the should be used for
sample collection if a reaction occurs following transfusion.
15 If a patient experiences pain close to the site of infusion, it’s likely to be classified a
reaction.
16 A nebuliser should be used to administer
at 5mg.
17 An assessment for bleeding from should
be conducted in an emergency situation.
18 There is no need to report transfusion
reactions if they do indeed occur.
19 Visual confirmation is sufficient to check for
in a patient’s recent urine sample.
20 A patient may be considered if they
experience pruritus accompanied by a headache.
Page 314
PART B
Question 1
The guidelines for infection control require dentists to
A. strictly abide by the rules set out within the document.
B. use their own judgement when putting the strategies into practice.
C. follow the example of well-established dental clinics.
1.12 Guidelines for Infection Control for

Dental Practitioners
The routine work practises outlined here are designed to reduce the number of
infectious agents in the dental practice environment; prevent or reduce the
likelihood of transmission of these infectious agents from one person or
item/location to another; and make items and areas as free as possible from
infectious agents. It is important to acknowledge that professional discernment is
essential in determining the application of these guidelines to the situation of the
individual dental practice environment. Individual dental practices must have their
own infection control procedures in place, which are tailored to their particular
daily routines. Professional awareness is critical when applying these guidelines to
the particular circumstances of each individual dental practice. Each dental
practitioner is responsible for implementing these guidelines in their clinical
practice and for ensuring their clinical support staff are familiar with and able to
apply them.
Page 315
Question 2
The email informs physiotherapists that
A. the option of consent ultimately lies with the patient.

B. information provided by the patient is confidential.
C. patient consent forms are a legally binding document.
To: All physiotherapists

From: Ken Macarthur, Head Physiotherapist
Subject: Patient consent forms
This is a courtesy email reminding all staff that it is standard practice to not only
provide the patient consent forms, but to also verbally go through all aspects of
the form with the patient prior to the commencement of treatment. The purpose of
this is to inform the patient of their rights and how we address the issue of a
collaborative decision making and informed consent between physiotherapist and
patient.
The patient’s condition and options for treatment must be discussed so they are
appropriately informed and are in a position to make decisions relating to their
treatment. They must also be informed that they may choose to consent or refuse
any form of treatment for any reason including religious or personal grounds. Once
they have given consent, they may withdraw that consent at any time.
Page 316
Question 3
What does the policy for manual handling equipment tell employers?
A. All areas of the hospital should be fitted with overhead tracking.
B. Assistance devices should be used over physically handling the patient.
C. Patients have the final decision on how they should be assisted.
Policy for manual handling equipment

The provision of ceiling hoist technology and air assisted patient lifting equipment
should be considered as the first line handling aid by employers as significant
evidence exists that their use reduces operator and patient injuries. Overhead
tracking should be installed in all new or refurbished facilities. This should cover
beds as a minimum, but should extend to ensuites and other areas of the facility
where patients are likely to require assistance. Once an assessment has been
made that equipment should be used for safe patient handling then equipment
should be made available and used, even in situations where the patient and/or
family’s preference is for it not to be used.
Page 317
Question 4
The purpose of the notice is to explain to occupational therapists that
A. confirmation of equipment is subject to availability at the time of request.

B. mattresses are of standard size so may not be suitable for all bed types.
C. patient factors must be considered prior to lodging a request form.
Equipment Request Form (ERF) for

Pressure Care Mattresses
It is the responsibility of the occupational therapist attending to the individual
patient to submit an Equipment Request Form (ERF) based on equipment eligibility
criteria. A pressure mattress may be appropriate when someone is at risk of a
pressure injury as evidenced by documented sound clinical reasoning and their
pressure injury risk is unlikely to significantly change. Environmental and equipment
considerations must be confirmed such as that a patient’s weight is within the safe
workload of the equipment requested. The size of the mattress must also be
compatible with other bed equipment and accessories and the patient has been
informed regarding the contraindications of placing items (e.g. continence
products, sheepskins, electric blankets, ill-fitting bed sheets) on top of the mattress.
Only after this confirmation should an ERF be submitted.
Page 318
Question 5
The memo about use of smart phones during surgery tells staff that
A. their use may be a violation of patient confidentiality.
B. they are to be used only by the surgeon
C. they can potentially lead to patient harm.
Memo: Restricted use of smart phones during surgery.
As smart phone technology has become increasingly common, it is now cause for
concern when used within the operating rooms, especially as a major source of
distraction. For this reason, the use of smart phones within the operating rooms will
now be restricted.
The undisciplined use of smart phones - whether for telephone, email or data
communication, and whether by the surgeon or other members of the surgical
team may compromise patient care. Whenever possible, members of the
operating suite team should only engage in urgent outside communication during
surgery. Personal and routine calls should be minimised and be kept as brief as
possible. Incoming calls should be forwarded to voicemail or to the reception desk
to be communicated promptly. Any use of a device or its accessories must not
compromise the integrity of the sterile field and special care should be taken to
avoid sensitive communications within the hearing of awake or sedated patients.
Page 319
Question 6
The main point of the extract on subcutaneous cannulas is to explain
A. the versatility of their design and function.

B. that they must only be used by registered nurses.
C. the need for a backup cannula in case of malfunction.
Subcutaneous cannulas
A subcutaneous cannula is a small plastic tube designed to carry medication into
a person’s body. One end, inserted by a registered nurse, sits just under the
person’s skin. The other end divides into two parts and is shaped like a Y. One part
of the Y-arm can be connected to a syringe driver or infusion pump; the other can
be used for subcutaneous injections. The nurse may insert a second cannula in a
different part of the body. This is in case the original cannula stops working and
ensures that there will be no delay in giving medications to the person you are
caring for. It can be especially useful if the original cannula stops working at night
when nurses may not readily available or have the same level of support as during
the day.
Page 320
Part C
Text 1: Witnessed resuscitation
attempts - a question of support.
The idea of supporting relatives who witness resuscitation is nothing new, with
research and reports going back to the 1980s. In 1996, the Research
Councils UK (RCUK) published a booklet called Should Relatives Witness
Resuscitation? Since then, practice has moved on, but many of its core elements
are still considered valid today. It was suggested that family members who
witness the resuscitation process may have a healthier bereavement, as
they will find it easier to come to terms with the reality of their relative’s death,
and may feel reassured that everything possible has been done. It
acknowledged that the reality of CPR may be distressing, but argued that it is “more
distressing for a relative to be separated from their family member” at this
critical time.
In the latest edition of its Advanced Life Support manual, the RCUK_______________
remains adamant that
“many relatives want the opportunity to be present during the attempted resuscitation of their
loved one.” But do they have the right to demand it? ‘The resuscitation team and the nurse
caring for the patient have the responsibility of deciding whether to offer relatives the
opportunity to witness a resuscitation attempt’ says Judith Goldman, clinician and researcher at
the University of Michigan, USA. ‘Sometimes resuscitation teams may decide not to offer
relatives the option of witnessing resuscitation; but this should never be based on their own
anxieties rather than on evidence- based practice’.
When a patient is admitted to intensive care the question may be asked by the medical team
whether the patient would want CPR. This would also provide an opportunity for witnessed
resuscitation to be discussed with patients and relatives upon admission. ‘The subject would
have to be approached sensitively, but ascertaining patients’ and/or relatives’ wishes before an
admission to intensive care would certainly help’ says Frank Lang, researcher for the European
Resuscitation Council. ‘Recent studies show both public support for witnessed resuscitation and
a desire to be included in the resuscitation process and of those who have had this experience;
over 90% would wish do so again” he says.
‘Still, the decision regarding whether
to be present during resuscitation should be left to the individual person because it’s certainly
not for everyone,’ he adds. ‘Medical teams also need to gauge whether witnessed resuscitation
would have benefits for the patient and/or the relatives, which can only be done through a
holistic assessment of the specific situation at the time.
Page 321
It needs to remain a personal approach’ he says. What this way of thinking suggests
is that regardless of research, witnessing resuscitation can be traumatic for all
involved, particularly for family members, so it seems appropriate that health
professionals explain everything that is happening. Even more so that a member of
the team, ideally the nurse caring for the patient in cardiac arrest, be designated for
that role and remain with the family during the whole process.
‘Nurses need to discuss the wishes of the patient and/or relatives as soon as
possible to act in the best interests of both while remaining
non-judgemental whatever the relatives decide, whether they choose to
be present or not, and support them in making the decision’ says Judith
Goldman. ‘Once it has been established that relatives want to be present, the nurse
should inform the resuscitation team leader, seek their approval and ask
them when the relatives should enter the resuscitation area. The team who are
providing direct care retains the option to request that the family be escorted away from the
bedside and/or out of the room if deemed appropriate’, she says.
Such decisions to request family removal are not taken lightly. ‘There are the more obvious
occasions that family members must be removed, for instance, if they disrupt the work of the
resuscitation team either through excessive grief, loss of self- control, exhibit violent or
aggressive behaviour or try to become physically involved in the CPR attempt’ she says. ‘But
the team also need to consider times when during a resuscitation attempt all members of staff
are fully occupied and there is no one available to stay with the family. This is especially hard
for them to take.’
If the family do remain present, and regardless of patient outcome, providing assistance is
crucial for families to get through such a stressful and shocking event. Frank Lang
recommends that ‘the nurse who is directing the family should point them towards all or any
available support service within the hospital as well as towards professional bereavement
counselling outside of the hospital. The latter provides distance from the scene and can help
with symptoms of post-traumatic stress disorder.’ Throughout any decision-making, however, it
is clear that the patient’s welfare, privacy and dignity must remain the utmost priority of the
resuscitation team
Page 322
7. In the first paragraph, the writer quotes the RCUK in order to
A. stress the significance of family involvement in resuscitation attempts.

B. show the significant benefits of family presence during resuscitation.
C. highlight that many now consider witnessed resuscitation outdated.
D. demonstrate that being witness to a resuscitation attempt is traumatic.
8. In the second paragraph, Judith Goldman says that witnessed resuscitation
A. should not be the sole decision of the resuscitation team.

B. needs to be made available to all families.
C. must not be denied because of personal feelings.
D. is requested by a large number of relatives.
9. In the second paragraph, the phrase ‘remains adamant’ is used to
A. argue that relatives should have the ultimate decision.

B. show that the opinion of the RCUK has not changed.
C. express that greater understanding is needed from staff.
D. emphasise RCUK’s opposition to excluding family.
10. In the third paragraph, Frank Lang suggests that patients and family members
A. would struggle to comprehend the process of CPR.

B. require follow up support from resuscitation teams.
C. have a good understanding of witnessed resuscitation.
D. would benefit from early consultation with staff.
Page 323
11. In paragraph four, the writer believes that a team member present at resuscitation
attempts
A. should provide the family with constant reassurance.

B. will find the experience as stressful as family members.
C. should focus on the patient rather than the relatives.
D. needs to explain the process to each individual family member.
12. What does Judith Goldman regard as important during resuscitation?
A. establishing that the resuscitation team are in charge.

B. that relatives are instructed on whether to be present or not.
C. the point at which family members enter or leave the scene.
D. remaining courteous when requesting relatives to leave.
13. In the sixth paragraph, Judith Goldman suggests that families who wish to be present
A. must understand that extra staff may not always be available.

B. at times struggle to understand why they cannot enter.
C. prefer to remain with the allocated member of staff.
D. are sometimes concerned about witnessing the resuscitation.
14. In the final paragraph, Frank Lang insists that despite the outcome of the resuscitation
attempt, families
A.are required to seek counselling as soon as appropriate.

B.should utilise the hospital network before outside assistance.
C. sometimes regret their decision to remain present.
D. will still often struggle to overcome the experience.
Page 324
Text 2: A smoker’s right to surgery
Smokers who do not try or do not succeed in quitting should not be offered a wide
range of elective surgical procedures, according to an editorial published in The
Medical Journal of Australia. The authors acknowledge this would be a controversial,
overtly discriminatory approach, but they say it is also evidence-based. Dr Matthew
Peters and colleagues from Concord Repatriation General Hospital say smokers who
undergo surgery have substantially higher risks, poorer surgical outcomes and therefore
consume more healthcare resources than non-smokers. Surprisingly, these new
concerns are not based on cardiac and respiratory risks, but increased wound infection.
"A randomised study examining
smoking cessation intervention before joint replacement surgery, saw wound infection rates
reduced from 27 per cent in continuing smokers to zero in those who quit smoking," Dr Peters said.
“Almost 8 per cent of breast reconstruction patients who smoke experience abdominal wall site
necrosis, compared with 1 per cent of non- smokers. These results are obviously significant.” He
believes that its much better that the prioritisation occurs on the basis of good evidence rather than
on a whim or some political influence. "If there was a health care system that had everything
________
patients need and want immediately, there wouldn’t be a problem. But we don’t have that and as
far as I’m aware no country truly does. You have to determine priorities," Peters says.
However, not everyone agrees. Professor Andrew Coats, dean of the University of Sydneys faculty
of medicine believes this is not accepted medical treatment. “You do not arrange patients based on
them being more deserving or less deserving. You give treatment based on need and how a
person will benefit. It’s the urgency of that need that’s the main factor." Coats says lifestyle factors
should only affect treatment in very limited circumstances. "If, because of lifestyle factors, a
treatment is not likely to work or it will be harmful, then obviously it should not proceed. But we
don’t take these factors into account in prioritising; that would be the end of the healthcare system
as we know it." He says if a doctor believes a patient could give up smoking and therefore reduce
complication rates, they should encourage the patient to quit, but he says you cannot withhold an
operation as punishment for not giving up. "Many people are not able to give up cigarettes. It is a
real chemical condition."
Dr Mike Kramer, the Royal College of Surgeons representative agrees that smokers need to be
treated differently. "You need to take risk into account. The risks of procedure versus the benefits,
and that is affected by the smoking status of the patient," he says. Kramer, a cardiothoracic
surgeon, says complications associated with smoking are so significant he will delay an operation
for the removal of a lung cancer so a patient can stop smoking for a minimum of four weeks before
an operation. "This is not a moral judgement or an ethical judgement. It is a pure clinical judgement
for the benefits of a patients outcome," he says.
Page 325
There is also the heavy burden of financial pressure that must be considered when
dealing with the limited health dollar. Reverend Norman Ford, the director of the
Caroline Chisholm Centre for Health Ethics, says while there should be no blanket ban
or refusal for any surgery, the allocation of public health funds needs to be taken into account.
"Why should non-smokers _______
fork out for smokers?" Ford says the additional costs of wound
infection complications should be calculated and smokers who refuse to quit before surgery
should pay the additional expense if wound infections occur. "If they give up smoking they should
be treated the same as non-smokers. If they dont give up smoking they should pay the
difference," he says. "Youve got to motivate them to stop smoking and the pocket is a great
motivator - if theyve got it. So their ability to pay should be means tested.”
The essence of this argument comes down to the question of whether people who are knowingly
doing things that may be harmful to their health are entitled to health care. Surgery is routinely
performed on diabetics, who also are at risk of increased postoperative complications. If surgery
can be denied to smokers, or even delayed, should the same treatment, or lack thereof be given
diabetics with poor glycaemic control because they don’t comply with diet or medications?
Refusing to operate on smokers could land us on a very slippery slope, eventually allowing
surgeons to choose to operate only on low risk patients. Perhaps it would be more prudent for
physicians to educate their patients about the risks of smoking, as well as other risk factors, prior
to surgery and entitle patients to make an informed decision about their healthcare
Page 326
15. What possible reason does the writer give for refusing current smokers the
opportunity for surgery?
A. the negative effects seen in systematic research

B. the overall increased costs to the hospital system
C. the known impact on the patient’s heart and lungs
D. the higher possibility of postoperative infection
16. In the second paragraph, Dr Peters says that prioritising patients
A. is unfortunately necessary.
B.is less expensive in the long run.
C. should start at a government level.
D. has been shown to reduce harmful outcomes.
17. In the second paragraph, the writer uses the term ‘on a whim’ to show Dr Peters’ belief
that
A. further research should be carried out.
B. current healthcare systems are not adequate.
C. the findings of recent research are remarkable.
D. careful consideration is extremely important.
18. In the third paragraph, Professor Coates says that treatment should be provided
A. to all patients based on a system of merit.

B. according to the necessity of the individual patient.
C. regardless of a patient’s lifestyle factors.

D. once a patient has reduced their intake of cigarettes.
Page 327
19. What does Dr Mike Kramer regard as a significant factor when treating a smoker?
A. the length of time a patient has refrained from smoking

B. providing an unbiased assessment of each individual
C. considering the ethical implications of each case
D. the patient’s attitude towards smoking cessation
20. In the fifth paragraph, Reverend Norman Ford says that when considering the
financial burden of healthcare
A. smokers should fund their own operations.

B. more public funding is needed to help smokers quit.
C. making a smoker pay incentivises change.
D. patients who smoke should not be held accountable.
21. In the fifth paragraph, what opinion is highlighted by the phrase ‘fork out’?
A. Patients that continue to smoke should still have rights.

B. Those that don’t smoke have less complications.
C. The public should not bear the cost of smokers’ healthcare.
D. Non-smokers are less of a burden on public funding.
22. In the final paragraph, the writer argues that treating smokers differently
A. is fair as other patients haven’t made such poor lifestyle choices.

B. could in turn lead to poor decisions concerning other patients.
C. may ultimately cause such patients to avoid having health checks.
D. may lead surgeons to discriminate against patients with diabetes.
Page 328
E2language Reading
Test V- Answer
1. B
2. C
3. A
4. D
5. C
6. A
7. B
8. 24 hours / twenty four hours (Text D)
9. (a) blood culture bottle/(an) appropriate blood culture bottle (Text A)
10. 5 minutes/five minutes (Text B)
11. Critical Care (admission) (Text D)
12. Systolic BP/blood pressure (Text C)
13. Aspirin containing products (Text B)
14. Opposite arm (Text A)
15. Category 3/life threatening (Text C)
16. Salbutamol (Text B)
17. Puncture sites or wounds (Text D)
18. Mild hypersensitivity and non-haemolytic febrile (Text A)
19. (signs of) haemoglobinuria (Text D)
20. Category 2/moderately severe (Text C)
Page 329
Part B
1- A
2- A
3- B
4- B
5- C
6- A
Part
Part CBBC
Part
Part
7- A
C.1
8- C
9- B
10- D
11- A
12- C
13- B
14- D
_________________________________________________
15- D
C.2 16- A
17- D
18- B
19- A
20-C
21- C
22- B
Page 330
15
OET Online Test 1
Page 331
Assessing Pain: Texts
Text A
Page 332
Text B
Pain Assessment Tools

Tools used for pain assessment have been selected on their validity, reliability and usability and are
recognised by pain specialists to be clinically effective in assessing acute pain. All values are documented on
the clinical observation chart as the 5th vital sign.
Three ways of measuring pain:
• Self report – what the child says (the gold standard)

• Behavioural – how the child behaves
• Physiological – clinical observations
Physiological indicators
Physiological indicators in isolation cannot be used as a measurement for pain. A tool that incorporates
physical, behavioural and self report is preferred when possible. However, in certain circumstance (for
example, the ventilated and sedated child) physiological indicators of pain can be helpful to determine a
patient’s experience of pain.
These include:
• heart rate may increase
• respiratory rate and pattern may shift from normal ie: increase, decrease or change pattern
• blood pressure may increase
• oxygen saturation may decrease
Text C
Wong-Baker faces pain scale
The Wong-Baker faces pain scale uses self report of pain to assess a patient’s experience of pain. It can be used
in children aged between 3 and 18 years of age, depending upon their cognitive ability.
Explain to the patient that each face helps us understand how much pain they have, and how this makes
them feel. Face 0 is very happy because he doesn't hurt at all (i.e has no pain). Face 2 hurts just a little bit.
Face 4 hurts a little more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can
imagine, although you don't have to be crying to feel this bad. Ask the person to choose the face that best
describes how he is feeling.
Page 333
Text D
FLACC: Face, Legs, Activity, Cry and Consolability
The FLACC is a pain assessment tool that uses that patient’s behaviour to
assess their pain experience. It can be used for children aged between
2 months and 18 years of age, and up to 18 years of age in children with
cognitive impairment and/or developmental disability.
Each category (Face, Legs etc) is scored on a 0-2 scale, which results in
a total pain score between 0 and 10. The person assessing the child should
observe them briefly and then score each category according to the
description supplied.
END OF PART A
Page 334
OET ONLINE – READING
TEST 1
A1
INSTRUCTIONS
Type all your *s in the * box provided.
One mark will be granted for each correct *.
* ALL questions. Marks are NOT deducted for incorrect *s.
Part A
TIME: 15 minutes
Look at the four texts, A-D, in the separate Reading Part A: Text Booklet.
For each question, 1-20, look through the texts A-D, to find the relevant information.
Type your *s in the * box provided.
* all the questions within the 15-minute time limit.
Your *s should be spelled correctly.
Information text
For each of the questions, 1 – 7, decide which text (A, B, C or D) the information comes from. You may use any letter
more than once.
In which text can you find information
1. regarding necessary considerations when assessing a child’s pain level?_ _________
2. the methods used to measure pain? ___________
3. specific factors to note when assessing a child’s pain? __________
4. a tool that uses behavioural responses to assess pain level. __________
5. the rating scale to use for self report when assessing pain? _________
6. how to assess a patient’s pain level via their facial expression?________
7. signs of pain to be aware of in a patient who is under sedation? _______
Page 335
each of the questions, 8-13, with a word or short phrase from one of the texts. Each * may include words, numbers or
both.
Rules of Use:
Spell all words correctly.
Use correct spacing between words.
Use correct punctuation.
Note: This is an automated system with a range of predetermined *s. As a result, sometimes a correct * choice may
be marked incorrect. Therefore, please refer to the * key to determine if your * is correct.
*
8- Which pain assessment tools should be used in children who are developmentally disabled or too young to speak?
_______________________________________________________
9- What is the maximum age for behavioural assessment of pain in an intellectually disabled patient?
_______________________________________________________
10 - What risk should you be aware of when assessing pain in children with disabilities?
_______________________________________________________
11- Who can help provide better assessment of pain in disabled children?
_______________________________________________________
12- Where should pain values be documented?

_______________________________________________________
13- How often should all children have their pain scores recorded?
_______________________________________________________
Questions 14 - 20
Complete the sentences, in questions 15-20, with a word or short phrase from one of the texts. Each * may include
words, numbers or both. Your *s should be spelled correctly.
14- Self reporting is considered to be _______________when measure pain in children.
15- You should avoid using__________________ observations on their own as a way of measuring pain.
16- You should ensure the patient understands they need to choose the__________________that most accurately
represents their mood when self reporting.
17- Don’t have patients self report if they lack the required __________________ability
18- Make sure to allocate a score of between__________________for each sub-group when evaluating the behavioural
responses of a child.
19- The maximum possible pain score should be given to a patient if you notice it is hard to __________________them
20- Pain should be assessed and recorded __________________analgesia.
Page 336
B1
The spicial access scheme should be used when :
A. the patient requires specialised treatment.

B. all other possibilities have been exhausted.
C. the standard of the product has been verified.
---------------------------------------------------------------------------------------------------------------------------------------------------------------
What needs to be considered when recommending the use of cough and cold medicines in children?
Select one:
A. The possible dangers.
B. The low success rate.
C. The age of the child.
Page 337
\
The memo tells us that the new form

Select one:
A. replaces all previous airway forms.
B. is designed to reduce airway incidences.
C. can be used in a variety of airway situations.
---------------------------------------------------------------------------------------------------------------------------------------------------------------
The guidelines inform us that pregnancy testing

Select one:
A. is compulsory for any woman who suspects she may be pregnant.
B. may result in scheduled treatment being postponed or cancelled.
C. should be conducted in accordance with established procedures.
Page 338
The policy recommends that vitamin K be given to infants
A. by a trained health professional.
B. within the first month of birth.
C. only if they are healthy.
---------------------------------------------------------------------------------------------------------------------------------------------------------------
The update on cosmetic and discretionary surgery informs us

A. who is eligible to provide surgery.
B. when surgery should be performed.
C. the process for approval of surgery.
Page 339
C1.1
Text: Healthy Ageing
The writer says the INTERHEART study found that stress
A. is conditional on how much money a person earns.
B. can be affected by a person’s level of social integration.
C. affects people from some nations more than others.
D. is worse in people who already have health concerns.

---------------------------------------------------------------------------------------------------------------------------------------------------------------
In the second paragraph, the writer cites several studies to suggest:
A. the quality of a person’s relationships is integral to their health.
B. being on your own as you age may lead to premature death.
C. some diseases are more affected by loneliness than others
D. there are many contributing factors that lead to poor health.

What does the phrase ‘the effect’ refer to?
A. Other issues that reduce mortality rates.
B. A person’s chance of staying healthy.
C. The influence of being on your own.
D. Having enough people in your life.
Page 340
What point does the writer make in the third paragraph?
Select one:
A. The causes of social isolation differ between the US and Europe.
B. More research has been done into social isolation than social integration.
C. Social integration assists in minimising heart disease by altering nerve impulses.
D. Social isolation affects women while social integration has a greater effect on men.
---------------------------------------------------------------------------------------------------------------------------------------------------------------
The writer suggests the ‘package’ developed by the WHO

Select one:
A. has a strong focus on saving money.
B. encourages elderly people to take responsibility for their lives.
C. fails to acknowledge dangers beyond lifestyle choices and eating habits.
D. carefully balances a range of issues that impact on an individual’s well-being.
Page 341
The phrase ‘in the shadows’ suggests that social participation
A. is difficult to understand.
B. has become hidden.
C. is largely unknown.
D. has been ignored.
In the fifth paragraph, the writer expresses the view that
A. the approach by the WHO is too simplistic.
B. people in low-income areas have worse health.
C. lifestyle factors are not the only cause of illness.
D. irresponsible behaviour causes most health problems.

---------------------------------------------------------------------------------------------------------------------------------------------------------------
The writer suggests that social participation is not encouraged in the WHO package because
A. studies of this kind would be challenging to complete.

B. it is a new area of research with limited data to support it.
C. they have an obligation to focus on areas that promote profits.
D. there is no indication it would make any difference to a person’s health.
Page 342
C1.2
Text: No Scientific Proof That Multivitamins Promote Heart Health
For questions 1 to 8, choose the answer (A, B, C or D) which you think fits best according to the text.
DrJoonseok Kim uses the expression ‘settle the controversy’ to suggest there is
Select one:
A. a lack of agreement about the efficacy of MVM supplement use.

B. confusion over the terms used to define cardiovascular disease.
C. a dispute over the findings from his latest published research.
D. misunderstanding about the methods used during his study.
What are Dr JoAnn Manson’s views on multivitamins?
A. Far too many people take them.

B. They help fight certain illnesses.
C. We still don't know enough about them.
D. They shouldn't replace a nutritional diet.
Page 343
The writer explains the systematic review and meta-analysis of the studies reviewed by Dr Kim to highlight
A. the amount of categories it covered.
B. how many people it included.
C. the age of the participants.
D. its global scope.

---------------------------------------------------------------------------------------------------------------------------------------------------------------
What does the word ‘they’ in the fourth paragraph refer to?
A. Multivitamins.
B. Some vitamins.
C. Health and well-being.
D. Cardiovascular events.
How do Dr Haslam and Dr Prasad feel about multivitamin use for cardiovascular disease
A. They are positive about their future application.
B. They believe that some help and some don’t.
C. Although they appear to be promising, ultimately they don’t work.
D. Scientifically speaking they are still one of the best options available.
Page 344
What particularly concerns Dr Manson?
A. The way some people take multivitamins instead of their prescribed medication.
B. The lack of understanding about the prolonged use of multivitamins.
C. The ineffectiveness of multivitamins in many patients.
D. The belief that multivitamins do no harm.
In the fifth paragraph, Dr Manson explains that supplements
A. should be regulated for use with particular diseases.
B. do have their place as a method of treatment.
C. work better in some people than others.
D. are helpful for vegetarians.

---------------------------------------------------------------------------------------------------------------------------------------------------------------
The writer mentions the Physicians’ Health Study II to highlight that supplements
A. are ineffective in most situations.
B. may work better depending on a person’s gender.
C. may work best when combined with other vitamins.
D. are still being investigated as a way of treating serious illness.
Page 345
OET ONLINE TEST 1
ANSWER
PART A
1. A
2. B
3. A
4. D
5. C
6. C
7. B
----------------------------------------------------------------------------------------------------
8. Physiological and behavioural
9. 18 years
10. Under-treating pain
11. Parents and care givers
12. On the clinical observation chart
13. Once per shift
----------------------------------------------------------------------------------------------------
14. Gold Standard
15. Clinical
16. Face
17. Cognitive
18. 0-2
19. Console
20. Before and after
Page 346
Part B
1. B
2. B
3. B
4. C
5. B
6. C
Part C
Extract 1
1. B
2. A
3. D
4. C
5. C
6. B
7. C
8. B
Extract 2
1. A
2. D
3. A
4. B
5. C
6. D
7. B
8. D
Page 347
16
OET Online Test 2
Page 348
Overweight and obese children: Texts
Text A
Growth Monitoring
The monitoring of children’s growth (and weight in particular) is an important role of all health
professionals. At every consultation (or at least yearly), health professionals need to have a
conversation with families and carers around children achieving a healthy weight.
“Ask and Assess – use percentile charts to monitor growth”

Growth status in children and adolescents (age 0-18 years old) needs to be assessed using
age- and sex-specific reference values, as the appropriate ratio of weight to height varies
during development.
Reference values for assessing and monitoring weight, length/height and BMI have been developed
by the World Health Organisation (WHO) and Centres for Disease Control and Prevention (CDC) in
the form of the childhood growth charts. The choice of chart depends on the age and gender of the
child. For children aged less than two years the WHO growth charts should be used. For children
between 2 and 18 year either the WHO or the CDC growth charts can be used. However, it is
important to ensure that the same chart is used over time.
Text B
Steps for discussing weight with families or carers
1. Make the family feel welcome and at ease.

2. Ask permission to discuss growth and development with the family.
3. Normalise the discussion of growth and development. Reassure the child and family that it is
standard practice in primary care.
4. Explain what is measured and why? (Weight, Height, BMI).
5. Encourage involvement of parents/carers when measuring weight and height.
6. Explain how the child’s growth tracks against the growth of all children. Engage the family in
plotting and interpreting the growth chart, using the growth charts as a tool.
7. Advise parents or carers of child’s growth status. Be sensitive and nonjudgmental but don’t
sugar-coat it. For example: “Tom’s BMI is… which places him above the healthy weight range.”
8. Use positive terminology to reinforce key concepts and advice:
• Use “healthy eating”, “eating” or “eating plan” rather than “diet” or “dieting”.
• Do not use ‘good’ or ‘bad’ to describe food or drinks – these terms reinforce a dieting
mentality and create blame and guilt.
• Let the family do most of the talking rather than you.
• Be realistic - make sure everyone in the room understands that long term changes have to be
made if the child is above the healthy weight range and that it will take time.
• Avoid inappropriate words, such as “Tom is obese.”
9. For adolescents, if appropriate, consider speaking to them without parent or carer present.
10. Agree on and develop an action plan.
Page 349
Text C
More than 25% of children and adolescents are overweight or obese. For obese children,
complications are more likely to develop because they are obese longer.
Risk factors for obesity in infants are low birth weight and maternal obesity, diabetes, and smoking.
After puberty, food intake increases; in boys, the extra calories are used to increase protein
deposition, but in girls, fat storage is increased.
For obese children, psychologic complications (eg, poor self-esteem, social difficulties, depression)
and musculoskeletal complications can develop early. Some musculoskeletal complications, such
as slipped capital femoral epiphyses, occur only in children. Other early complications may include
obstructive sleep apnea, insulin resistance, hyperlipidaemia, and non-alcoholic steatohepatitis.
Risk of cardiovascular, respiratory, metabolic, hepatic, and other obesity-related complications
increases when these children become adults.
Text D
The possibility of obesity persisting into adulthood depends partly on when obesity first develops:
• During infancy: Low possibility

• Between 6 months and 5 yrs.: 25%
• After 6 yrs.: > 50%
• During adolescence if a parent is obese: > 80%
In children, preventing further weight gain, rather than losing weight, is a reasonable goal. Diet
should be modified, and physical activity increased. Increasing general activities and play is more
likely to be effective than a structured exercise program. Participating in physical activities during
childhood may promote a lifelong physically active lifestyle. Limiting sedentary activities
(eg, watching TV, using the computer or handheld devices) can also help. Drugs and surgery are
avoided but, if complications of obesity are lifethreatening, may be warranted.
END OF PART A
Page 350
Text D
The possibility of obesity persisting into adulthood depends partly on when obesity first develops:
• During infancy: Low possibility

• Between 6 months and 5 yrs.: 25%
• After 6 yrs.: > 50%
• During adolescence if a parent is obese: > 80%
In children, preventing further weight gain, rather than losing weight, is a reasonable goal.
Diet should be modified, and physical activity increased. Increasing general activities and play is more
likely to be effective than a structured exercise program. Participating in physical activities during
childhood may promote a lifelong physically active lifestyle. Limiting sedentary activities (eg, watching
TV, using the computer or handheld devices) can also help. Drugs and surgery are usually avoided but, if
complications of obesity are life threatening, may be warranted.
END OF PART A
Page 351
TEST 2
A2
Questions 1 – 6
For each of the questions 1 – 6, decide which text (A, B, C or D) the information comes from. You
may use any letter more than once.
1. how to approach giving advice about overweight children? _________
2. how often to discuss a child's weight? _________
3. possible causes for obesity in infants and adolescent females? _________
4. the standards used to measure the development of children? _________
5. other conditions which are associated with obesity in children? _________
6. strategies to help stop children's weight increasing? ________
Answer each of the questions, 7-13, with a word or short phrase from one of the texts. Each answer
may include words, numbers or both.
7- If a mother has _________________ , smokes, or is herself obese it increases the risk of obesity in her child.
8- You should discuss healthy weight in children with parents _________________at a minimum.
9- Make sure to clarify the types of areas that are_________________and the reasons why.
10- The family should be encouraged to participate in the use of the _________________ .
11- Convey information about the_________________of children in an understanding way.
12- If a child is obese for a length period of time, then they are more likely to experience_________________ .
13- The family needs to appreciate that_________________changes must occur in children whose weight
exceeds what is healthy.
Page 352
Questions 14 – 20
Answer each of the questions, 14 – 20, with a word or short phrase from one of the texts. Each answer may
14- What influences the type of chart used to calculate a child's growth status?
________________________________________________________
15- What does the WHO and CDC assess and monitor when forming childhood growth charts?
________________________________________________________
16- What increases in children once they reach pubescence?
________________________________________________________
17- If it is already in the family, what is the likelihood that a teenager will remain obese?
________________________________________________________
18- What needs to be agreed upon and developed with the family of an obese child?
________________________________________________________
19- What psychological symptoms are known to appear early in obese children?
________________________________________________________
20 If the situation is serious enough, what might be required in some children?
________________________________________________________
Page 353
B2
In this part of the test, there are six short extracts relating to the work of health professionals. For questions 1
to 6, choose the answer (A, B or C) which you think fits best according to the text.
The instructions explain that when making emergency phone referrals
A. GRACE must always be contacted first.

B. a referral must always be faxed right away.
C. the On-call Registrar must always grant approval.
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To eliminate the risk of contamination from infectious agents or certain types of fluids, aprons and gowns should
be
A. worn over all clothing.

B. changed when they become soiled.
C. discarded if they are damaged.
Page 354
The purpose of the email about oral health clinical indicators is to
A. explain why the reports were introduced.

B. highlight what the reports have achieved.
C. provide future details about upcoming reports.
---------------------------------------------------------------------------------------------------------------------------------------------------------------
The policy informs us that doctors treating athletes at sporting events in the UK
A. must be appropriately licensed.

B. are expected to have adequate training.
C. cannot treat anyone from another country.
Page 355
The purpose of the guidelines on remote consultations is to
A. help practitioners decide an appropriate course of action.

B. advise practitioners about a growing trend in modern medicine.
C. recommend a series of questions for practitioners to ask their patients.
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According to the extract, prescription medicines

Select one:
A. are often unavailable due to stock shortages.
B. can be purchased as special orders from manufacturers if required.
C. may show as being unavailable even though they can still be bought.
Page 356
C2.1
For questions 1 to 8, choose the answer (A, B, C or D) which you think fits best according to the text.
The phrase 'the first camp' refers to dental professionals who

Select one:
A. cannot agree on the effectiveness of fluoride.
B. believe keeping teeth clean prevents cavities.
C. feel that no amount of brushing reduced plaque.
D. are certain about how the entire process works.
Philippe Hujoel’s comments in the first paragraph indicate that he believes

Select one:
A. no one knows how to prevent plaque.
B. everyone has plaque on their teeth.
C. only fluoride can remove plaque.
D. plaque is impossible to remove.
Page 357
What does the word 'it' in the second paragraph refer to?
A. fluoride.
B. Hujoel's team.
C. cavity prevention.
D. the intensity of oral hygiene.
By examining clinical trials from the US and UK, Philippe Hujoel says his team established that
A. fluoride should be placed in all water supplies.
B. regular brushing is the best way to reduce cavities.
C. children need to be encouraged to brush their teeth.
D. intense oral hygiene is effective at cleaning teeth only.
---------------------------------------------------------------------------------------------------------------------------------------------------------------
Matthew Messina from the American Dental Association suggests that

Select one:
A. scientific advances have reduced tooth decay.
B. fluoride isn’t as important as many people believe.
C. it takes a wide-ranging approach to prevent cavities.
D. increased life expectancy results in more dental disease.
Page 358
Darryl Bosshardt’s comments indicate that he believes
Select one:
A. it is up to individuals to make their own choice about fluoride.
B. fluoride is still the best way to protect teeth.
C. there are no alternatives to fluoride.
D. fluoride is a dangerous product.
---------------------------------------------------------------------------------------------------------------------------------------------------------------
The writer includes the statement that fluoride-free toothpaste from Tom’s of Maine does not carry an anti-
cavity claim to suggest that
Select one:
A. this is the best toothpaste for people to buy.
B. some types of toothpaste may not prevent decay.
C. they don’t like offering this type of toothpaste.
D. it is difficult to decide which toothpaste works best.
Page 359
n the final paragraph, the writer uses Philippe Hujoel’s words to highlight that
Select one:
A. not everyone takes the same approach to oral hygiene.
B. some food can contribute to the problem.
C. fluoride is the best option.
D. not all diets are practical.
Page 360
C2.2
STRESS AND BURNOUT
What concern does the writer express about ICM clinicians?
A. There are not enough of them to treat the rising number of sick people.
B. The numbers of those who work with children has increased.
C. Many may not be performing effectively because of a pressured work environment.
D. They usually work longer hours than is recommended.
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In the second paragraph, the writer suggests that burnout
A. poses problems for the intensive care setting.

B. has become more prominent in recent years.
C. isn’t currently able to be measured.
D. is very similar to depression.
Page 361
What does the writer say about burnout syndrome in Australian emergency medicine clinicians?
A. Not enough emphasis is placed on ways to relieve pressure.

B. Training will help ICU staff better understand how they’re feeling.
C. The situation is made worse by of the level of responsibility placed on ICU staff.
D. The impact of the condition is dependent on a range of personal choices.
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The writer uses the term ‘interconnected’ to indicate that burnout can
Select one:
A. make it difficult for staff to work well together.
B. impact on medical staff and patients.
C. cause some healthcare professionals to leave the industry.
D. affect clinicians for many years after they are first diagnosed.
Page 362
What does the writer suggest about the problem of burnout in the fifth paragraph?
A. It is being made worse by a reduction in healthcare professionals.
B. It is developing in line with broader societal issues.
C. It isn’t going to be solved any time soon.
D. It affects men more than women.

---------------------------------------------------------------------------------------------------------------------------------------------------------------
What point does the writer make in the sixth paragraph?
A. It is difficult for staff to change their current behaviour.
B. The existing approach within hospitals is there for a reason.
C. Management should do more to improve working conditions.
D. There needs to be a multifaceted response to workforce welfare.
The writer explains that the College of Intensive Care Medicine and the Australian and New Zealand Intensive Care
Society
A. are integral in measuring the health of practitioners.
B. should take action before the situation worsens for practitioners.
C. require assistance from other sectors in order to help practitioners reduce their workload.
D. need to educate patients about how their actions affect practitioners.
Page 363
In the final paragraph, the writer users the word 'paucity' to suggest that
Select one:
A. not enough is being done to help practitioners.
B. practitioners need to do more to help themselves.
C. the ICU may not be a suitable place for all practitioners to work.
D. it is natural that some practitioners handle stress better than others.
Page 364
OET ONLINE TEST 2
ANSWER
PART A
1. B
2. A
3. C
4. A
5. C
6. D
-------------------------------------------------------------------------------------------------------------
7. Diabetes
8. Yearly
9. Measured
10. Growth chart
11. ?? Healthy
12. complication
13. long - term
-----------------------------------------------------------------------------------------------------------------
14. The ega and gender
15. Weight , length/height , BMI
16. Poor intake
17. > 80%
18. An action plan
19. Poor self-esteem , social difficulties , depression
20. Drugs and surgery
Page 365
Part B
1. C
2. A
3. B
4. A
5. A
6. C
Part C
Extract 1
1. B
2. C
3. D
4. D
5. C
6. A
7. B
8. C
Extract 2
1. A
2. C
3. B
4. B
5. B
6. D
7. A
8. A
Page 366
17
OET Online Test 3
Page 367
Snakebite in children: Texts
Text A
Background
Snakebite is uncommon in Victoria and envenomation (systemic poisoning from the bite) is rare. The bite site
may be evidenced by fang marks, one or multiple scratches. The bite site may be painful, swollen or bruised,
but usually is not for snakes in Victoria.
There are no sea snakes in Victoria, but land-based snakes can swim.
Major venomous snakes in Victoria and effects of envenomation:
Systematic Cardiovascular
Snake Coagulopathy Neurotoxicity Myotoxicity TMA
symptoms effects
- Collapse (35%)
Brown VICC Rare and mild 50% 10%
Cardiac arrest (5%)
Tiger VICC 30% 20% Common Rare 5%
Red- Mild increase - Uncommon Common - -

bellied
Text C in aPITT and Often
black INR with significant
normal bite site pain
fibrinogen, and limb
usually no swelling
significant
bleeding
VICC: Venom-induced consumptive coagulopathy (abnormal INR, high aPTT, fibrinogen very low, D-dimer
high).
Myotoxicity muscle pain, tenderness, rhabdomyolysis
Systemic Symptoms see history and examination.
TMA: thrombotic microangiography. Haemolysis with fragmented red blood cells on blood film,
thrombocytopenia and a rising creatinine.
Page 368
Text B
Assessment
Focus on evidence of envenomation.
• Once the possibility of snakebite has been raised, it is important to determine whether a child
has been envenomed to establish the need for antivenom.
• This is usually done taking into consideration the combination of circumstances, symptoms,
examination and laboratory test results.
• Most people bitten by snakes in Australia do not become significantly envenomed.
History and Examination
Circumstances Symptoms Examinations
- Confirmed or witnessed - Headache - Evidence of a bite/ multiple

bite versus suspicion that - Diaphoresis bites
bite might have occurred - Evidence of venom movement
Text C - Nausea or vomiting
- Abdominal pain (e.g. sowllen or tender draining
- Were there multiple bites?
- Diarrhoea lymph nodes)
- When?
- Where? - Blurred or double vision - Neurotix paralysis (ptosis,
- First aid? - Slurring of speech ophthalmoplegia, diplopia,
- Past history? - Muscle weakness dysarthria, limb weakness,
- Medications? - Respiratory distress respiratory muscle weakness)
- Allergies? - Bleeding from the bite site or - Coagulopathy (bleeding gums,
elsewhere prolongued bleeding from
- Passing dark or red urine venepuncture sites or other
- Local pain or swelling at bite wounds, including bite site)
site - Muscle damage (muscle
- Muscle pain tenderness, pain on movement
- Pain in lymph nodes draining weakness, dark or red urine
the bite area indicating myoglobinuria)
- Loss of consciousness/collapse
and/or convulsions
Page 369
Text C
Snakebite Management Flowchart
Page 370
Text D
Giving Antivenom
• Antivenom is indicated in all children where there is evidence of envenomation.

• Giving antivenom should occur in consultation with a clinical toxicologist.
• Dilute one vial in 100mls of 0.9% saline and give IV over 15-30 min.
• If the child is in cardiac arrest and this is thought to be due to envenomation, then give undiluted
antivenom via rapid IV push.
• There is no weight based calculation for antivenom (the snake delivers the same amount of venom
regardless of the size of the child). One vial of antivenom is enough to neutralise the venom that can be
delivered by one snake. Clinical recovery takes time after antivenom administration and multiple vials do
not speed recovery.
At discharge, ensure that the family is given advice on how to recognise serum sickness:
• Occurs in about 30% of children given antivenom.

• Tends to occur 4 – 14 days following antivenom administration.
• Consists of flu-like symptoms, fever, myalgia, arthralgia and rash.
• A letter should also be written to the child’s GP regarding this.
Page 371
TEST 3
A3
TIME: 15 minutes
Look at the four texts, A – D, in the separate Text Booklet.
For each question, 1 – 20, look through the texts, A – D, to find the relevant information.
Write your answers on the spaces provided in this Question Paper.
Your answers should be correctly spelt.
Questions 1 – 7
For each of the questions, 1 – 7, decide which text (A, B, C or D) the information comes from. You may use any letter more than
once.
1. the factors to consider when evaluating snakebite?________
2. what a snakebite can look like? ________
3. possible types of snakebite and their reactions? ________
4. signs that a child may be bitten by a poisonous snake? ________
5. when to release a pressure immobilisation bandage? ________
6. knowing when it is safe to discharge a child who has not been envenomed? ________
7. to tell parents to look for in a child having a response to serum? ________
Answer each of the questions, 8-12, with a word or short phrase from one of the texts. Each
8- If you suspect a snakebite has occurred, you must decide whether or not the child has
been ___________________ .
9- Substantial pain and swelling is a likely sign that the child has been bitten by a ___________________ snake.
10- If clinical evidence warrants administration of antivenom, you should ensure it is done in conjunction with a
___________________ .
11- You will need to affix a ___________________ if it hasn't been done.
12- When deciding how much antivenom to administer, ___________________ is considered sufficient for each
child irrespective of their body weight.
Page 372
Questions 13 – 20
Answer each of the questions, 13 – 20, with a word or short phrase from one of the texts. Each
13- What TWO signs should you look for if snakebite is suspected?
_________________________________________________________
14- When assessing a child, what might indicate the presence of venom movement?
_________________________________________________________
15- In cases where neurotoxicity is rare or not severe, what type of snakebite could it indicate?
_________________________________________________________
16- After removing the PIB, when should you conduct another blood test if there is no evidence of poisoning from a
snakebite?
_________________________________________________________
17- What TWO anti-venoms should you give to a child with signs of envenomation?
_________________________________________________________
18- What quantity and strength of saline should each vial of anti-venom be diluted in?
_________________________________________________________
19- What time of day should discharge occur?
_________________________________________________________
20 - After anti-venom is administered, how long does it usually take for serum sickness to develop?
_________________________________________________________
Page 373
B3
The purpose of the email to hospitals about prescribing of antibiotics is to
Select one:
A. encourage them to implement appropriate procedures.
B. remind them of the seriousness of the issue.
C. advise them of upcoming changes.
---------------------------------------------------------------------------------------------------------------------------------------------------------
According to the memo, when keeping records staff should ensure
Select one:
A. they reflect everything that occurred.
B. important information is written down first.
C. their colleagues will be able to understand them.
Page 374
Why is the Queensland Bedside Audit conducted each year?
Select one:
A. to improve the quality of health service supply.
B. to find out how parties feel about their treatment.
C. to allow facilities to make advancements in technology.
---------------------------------------------------------------------------------------------------------------------------------------------------------
The policy extract tells us that
Select one:
A. all haemophilia patients must be treated in a registered HTC.
B. only haemophilia patients with a factor level above 30% need to be treated in a HTC.
C. the risks of being treated in a non-HTC facility have to be conveyed to relevant haemophilia patients.
Page 375
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Page 376
C3.1
The writer uses the percentages in the first paragraph to highlight
A. the size of the study.
B. the illnesses identified by the study.
C. the significance of the results of the study.
D. the differences between certain groups who took part in the study.
---------------------------------------------------------------------------------------------------------------------------------------------------------
What does Max Griswold, the lead author of the study, say concerns him?
A. the fact that alcohol is consumed in larger quantities now than in the past.
B. the misconception that in some instances alcohol may be good for you.
C. the lack of education available about the effects of alcohol.
D. the amount of ways alcohol has to make people sick.
What does the word ‘they’ in the second paragraph refer to?
A. Types of threats.
B. New discoveries.
C. Number of drinks.
D. Previous outcomes.
Page 377
The writer uses the expression ‘went further’ to indicate EmmanuelaGakidou
A. would have liked the study to look at more cases.

B. wants more people to reduce the amount they are drinking.
C. believes the suggestions made by Max Griswold aren't enough.
D. isn't happy about the lack of action since the 2014 World Cancer Report.
Study co-author Emmanuela Gakidou suggests alcohol consumption
A. should not be if concern if current levels are monitored.

B. must be addressed by governments immediately.
C. has been increasing at an alarming rate.
D. is an excellent source of revenue.
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Page 378
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Page 379
C3.2
.
What concern does the writer express in the second paragraph?
A. Empathy isn't fully understood by some health professionals.

B. Sympathy can impede on professionalism in a clinical setting.
C. Health professionals don't equally display empathy and sympathy.
D. Empathy and sympathy are often confused by health professionals.
Page 380
What does the word ‘it’ in the fourth paragraph refer to?
A. Touch.
B. Oxytocin.
C. The work of a nurse.
D. Non-verbal communication.
The writer suggests technology has led to reduced levels of empathy because
A. it means people don't always need to be in the same room.
B. it sometimes results in people becoming preoccupied.
C. it causes an extra level of stress for some people.
D. it can create greater distance between people.
Page 381
In the final paragraph, the writer suggests the best way to improve empathy is to
Select one:
A. fund research into the issue.
B. utilise new lab-focussed initiatives.
C. pay greater attention to the patient.
D. undertake communication-based study.
Page 382
OET ONLINE TEST 3
ANSWER
PART A
1. B
2. A
3. A
4. B
5. C
6. C
7. D
---------------------------------------------------------------------------------------------------------
8. Envenomed
9. Red - bellied black
10. Clinical toxology
11. PIB ( Pressure immobillisation bardage )
12. One vial of antivenom
---------------------------------------------------------------------------------------------------------
13. Fand marks, one or multiple scratches
14. Swollen or tender draining lymph nodes
15. A brown snake bite
16. 1 hour
17. One vial of tiger, one of brown
18. 100 mls of 0.9%
19. In daylights hours
20. 4 – 14 days
Page 383
Part B
1. A
2. C
3. A
4. C
5. C
6. B
Part C
Extract 1
1. C
2. B
3. A
4. C
5. B
6. D
7. B
8. A
Extract 2
1. D
2. A
3. B
4. D
5. A
6. D
7. C
8. C
Page 384
18
OET Online Test 4
Page 385
Hashimoto’s Thyroiditis: Texts
Text A
Hashimoto Thyroiditis Clinical Presentation
History
Hashimoto’s thyroiditis is an autoimmune condition in which the body perceives its own tissue as foreign.
It is the leading cause of hypothyroidism (underactive thyroid) in the Western World. Common, early presenting
symptoms of hypothyroidism, such as fatigue, constipation, dry skin, and weight gain, are nonspecific.
Physical Examination
Physical findings are variable and depend on the extent of hypothyroidism and other factors such as age.
Findings include the following:
Puffy face
Cold, dry skin, which may be rough and scaly - Skin may appear yellow but does not involve the sclera,
which distinguishes it from the yellowing of jaundice due to hypercarotenemia
Peripheral oedema of hands and feet, typically non-pitting
Thickened and brittle nails (may appear ridged)
Hair loss involving the scalp, the lateral third of the eyebrows, and possibly skin, and facial hair
Elevated blood pressure (typically diastolic hypertension) - Most often, blood pressure is normal or
even low
Diminished deep tendon reflexes and the classic prolonged relaxation phase, most notable and initially
described at the Achilles tendon (although it may be present in other deep tendon reflexes as well)
The thyroid gland is typically enlarged, firm, and rubbery, without any tenderness or bruit;
it may be normal in size or not palpable at all.
Voice hoarseness
Slow speech
Impairment in memory function
Website: http://oetonline.net.au This resource was developed by OET Online Email: [email protected]
Page 386
Text B
Testing Recommendations
Serum TSH Test

In the presence of suggestive symptoms and physical findings, a serum TSH (thyroid stimulating hormone) test
is needed for the diagnosis of primary hypothyroidism, and it serves to assess the functional status of the
thyroid. This should be followed up periodically to monitor for symptoms of hypothyroidism and to detect any
rise in TSH or cholesterol levels. Checks can usually be performed every 6-12 months.
Free T4 test
A free T4 is usually needed to correctly interpret the TSH in some clinical settings.
T3 test
A low T3 level and a high reverse T3 level may be of additional help in the diagnosis of nonthyroidal illness.
Ultrasonography
This is useful for assessing thyroid size, echotexture, and, most importantly, whether thyroid nodules are
present. Ultrasonographic study aids in confirming the presence of a thyroid nodule, in defining a nodule as
solid or cystic, and in defining features suggestive of malignancy, such as irregular margins, a poorly defined
halo, microcalcification, and increased vascularity on Doppler interrogation.
Page 387
Text C
Thyroid Levels Chart
Condition TSH T4 T3 Notes
Can also occur with

Lab error High High High TSH-secreting
tumour (very rare)
Thyroid peroxidise
Hashimotos thyroiditis antibodies high in 90%
High Low Low
(common cause of Hashimotos
hypothyroidism)
May also occur in

patients with
Sub-clinical (mild) High Normal Normal hypothyroidism not
hypothyroidism receiving adequate
thyroxine replacement
For treatment of Hashimoto's thyroiditis synthetic T4 or thyroxine (levothyroxine) should be prescribed at the
correct dosage.
Average full replacement dose: 1.7 mcg/kg/day (e.g., 100 to 125 mcg/day for a 70 kg adult) orally.
Older patients may require less than 1 mcg/kg/day.
Doses greater than 200 mcg/day orally are seldom required.
Page 388
Text D
Exam Date: 03 Jul 2018
Exam: ULTRASOUND THYROID
Clinical History
? Thyroiditis.
Findings
The thyroid gland is of normal size. The right lobe measured 52 x 11 x 14mm and left lobe 53 x 7 x 11mm.
The gland is generally heterogeneous but no discrete nodules or masses are seen. There is increased
vascularity that is associated.
No retrosternal extension is seen and no masses are seen in the position of the parathyroid gland.
The capsule is intact.
Comment
There is evidence of a heterogeneous thyroid gland in keeping with
thyroiditis. No dominant thyroid nodule is noted but a progress ultrasound would be useful to ensure small
nodules do not change in size.
END OF PART A
Page 389
TEST 4
A4
TIME: 15 minutes
Look at the four texts, A-D, in the separate Reading Part A: Text Booklet.
For each question, 1-20, look through the texts A-D, to find the relevant information.
Type your answers in the Answer box provided.
Your answers should be spelled correctly.
Information text
For each of the questions, 1 – 7, decide which text (A, B, C or D) the information comes from.
1. signs that indicate characteristics of hypothyroidism? _______

2. the use of ultrasound scans when assessing thyroid function? _______
3. reference ranges for thyroid function tests? _______
4. hormones which determine the status of a patient’s thyroid? _______
5. treatment options for Hashimoto’s thyroiditis? _______
6. different types of thyroid conditions? _______
7. dosage rates for thyroid replacement medication? _______
8- What can the face of a patient suffering with Hashimoto's thyroiditis look like?
______________________________________________________________
9- If a Hashimoto's patient has high blood pressure, what does it usually indicate?
______________________________________________________________
10- Which test is often required to understand TSH results?
______________________________________________________________
11- How often should the TSH level be checked if hypothyroidism is present?
______________________________________________________________
12- What medication is used to treat Hashimoto's thyroiditis?
______________________________________________________________
13- How long will treatment for Hashimoto’s thyroiditis typically last?
______________________________________________________________
14- What can occur if a patient isn’t receiving enough medication?
______________________________________________________________
Page 390
Questions 15 - 20
Complete the sentences, in questions 15-20, with a word or short phrase from one of
the texts. Each answer may include words, numbers or both. Your answers should be
spelled correctly.
15- A patient’s ______________can affect the type of symptoms they display.
16-Nonthyroidal illness can be detected via a___________________.
17- Check for a_________________ if a patient returns a high result in all tests.
18- Irregular margins in a patient with nodules may indicate________________.
19-The average medication dose for a 70kg adult is __________________ a day.
20-The amount of medication a patient receives may need to be_________________from
time to time.
Page 391
B4
Page 392
Page 393
Page 394
C4.1
Page 395
_____
Page 396
Page 397
_______
Page 398
C4.2
Page 399
Page 400
Page 401
Page 402
OET ONLINE TEST 4
ANSWER
PART A
1. A
2. B
3. C
4. B
5. D
6. C
7. C
----------------------------------------------------------------------------------------------
8. Puffy
9. diastolic hypertension
10. free T4 test
11. every 6 - 12 months
12. synthetic T4 or thyroxine
13. throughout the patient's lifetime
14. sub-clinical hypothyroidism
------------------------------------------------------------------------------------------------
15. Age
16. T3 test
17. Lab error
18. Malignancy
19. 100-125 mcg
20. Adjusted
Page 403
Part B
1. B
2. A
3. A
4. C
5. B
6. B
Part C
Extract 1
1. D
2. B
3. C
4. B
5. D
6. A
7. C
8. A
Extract 2
1. C
2. B
3. D
4. B
5. B
6. A
7. A
8. D
Page 404
19
OET Online Test 5
Page 405
Vitamin C Deficiency: Texts
Text A
Scurvy is a life-threatening condition due to dietary vitamin C deficiency.

Those affected are mostly refugees or victims of famine, alcoholics, older
people, fad dieters, or children with autism or idiosyncratic behavioural
abnormalities. Diagnosis is often delayed due to incomplete review of dietary
history.
Vitamin C deficiency may result from a diet deficient in fresh fruits and
vegetables. Also, cooking can destroy some of the vitamin C in food.
The following conditions can significantly increase the body’s requirements for
vitamin C and the risk of vitamin C deficiency:
Pregnancy
Breastfeeding
Disorders that cause a high fever or inflammation
Diarrhoea that lasts a long time
Surgery
Burns
Smoking, which increases the vitamin C requirement by 30%
Page 406 Email: [email protected]

Text B
The recommended daily intake of vitamin C varies by age, gender, pregnancy,

lactation, and smoking status.

Text C
Symptoms
The symptoms of scurvy develop only after a few months of deficiency.
Adults feel tired, weak, and irritable. They may lose weight and have vague muscle and
joint aches.
Bleeding may occur under the skin (particularly around hair follicles or as bruises), around
the gums, and into the joints. The gums become swollen, purple, and spongy. The teeth
eventually loosen. The hair becomes dry and brittle, and the skin becomes dry, rough, and
scaly. Fluid may accumulate in the legs. Anaemia may develop. Infections may develop, and
wounds do not heal.
Infants may be irritable, have pain when they move, and lose their appetite. Infants do not
gain weight as they normally do. In infants and children, bone growth is impaired, and
bleeding and anaemia may occur.
Normal examination has also been reported, presumably when symptoms have
developed in the setting of very low but not critical body stores.
Examination
Although no consistent order of presenting signs is established, the earliest signs of scurvy
are often gingival abnormalities, and a comprehensive examination of the mouth when
scurvy is recommended in patients presenting relatively early.
If the test is available, measuring the vitamin C level in blood can help establish diagnosis.
Blood tests to check for anaemia.
In children, x-rays to check for impaired bone growth.
Treatment
For scurvy in adults, ascorbic acid 100 to 500 mg orally twice daily must be given for 1 to
2 weeks, until signs disappear, followed by a nutritious diet supplying 1 to 2 times the daily
recommended intake of fresh fruits and vegetables.
In scurvy, therapeutic doses of ascorbic acid restore the functions of vitamin C in a few days.
The symptoms and signs usually disappear over 1 to 2 weeks. Chronic gingivitis with
extensive subcutaneous haemorrhage persists longer.

Text D
VITAMIN C EXCESS AND TOXICITY
High doses of vitamin C are usually not toxic to healthy adults. Occasionally, higher doses
cause nausea or diarrhoea and interfere with the interpretation of some blood test results.
Some people take high doses of vitamin C because it is an antioxidant, which protects cells
against damage by free radicals. Free radicals are thought to contribute to many disorders,
such as atherosclerosis, cancer, lung disorders, the common cold, eye cataracts, and
memory loss. Whether taking high doses of vitamin C protects against or has any beneficial
effect on these disorders is unclear. Evidence of a protective effect against cataracts is
strongest.

TEST 5
A5
Part A
TIME: 15 minutes
Vitamin C Deficiency: Questions
Questions 1 - 7
For each of the questions, 1 - 7, decide which text (A, B, C, or D) the information comes from. You may use any
1) the types of people usually affected by scurvy? _______

2) the physical effects of scurvy? _______
3) tests that can be conducted to check for scurvy? _______
4) adequate intake totals for vitamin C each day? _______
5) the effects of taking high doses of vitamin C? _______
6) conditions that increase a person’s need for vitamin C? _______
7) recovery time for a patient suffering from scurvy? _______
Information text
Questions 8 - 13
Complete each of the sentences, 8 - 13, with a word or short phrase from one of the texts.
Each answer may include words, numbers, or both.
8- Scurvy takes only a _________________of deficiency to develop.

9- In infants and children, _________________and anaemia may be present.
10- Incomplete review of dietary history frequently results in diagnosis
being _________________.
11- RDA sufficiently meets the vitamin C requirements in _________________of patients.
12- 75mg of vitamin C daily is recommended for women who are_________________.
13- It takes only a few days' worth of _________________ for the normal functions of vitamin
C to return.
Page 410
Questions 14 - 20
Answer each of the questions, 14 - 20, with a word or short phrase from one of the texts.
Each answer may include words, numbers or both.
14- What is frequently seen as an early indication of scurvy?

________________________________________________
15- What can occur in the gums, joints and under the skin of a patient with scurvy?
________________________________________________
16- How many extra milligrams each day of vitamin C does a smoker require?
________________________________________________
17- What increases the need for vitamin C by 30%?
________________________________________________
18- What is the maximum amount of vitamin C per day that should be given to infants?
________________________________________________
19- What do high levels of vitamin C protect cells from?
________________________________________________
20- Which condition is most likely to benefit from higher levels of vitamin C?
________________________________________________
Page 411
B5
Page 412
Page 413
Page 414
C5.1
Page 415
Page 416
Page 417
Page 418
C5.2
Page 419
Page 420
Page 421
OET ONLINE TEST 5
ANSWER
----------------------------------------------------
Part A
1. A
2. C
3. C
4. B
5. D
6. A
7. C
-----------------------------------------------------------------------
8-few months
9-Bleeding
10-Delayed
11-97% to 98%
12-not pregnant
13-ascorbic acid
-----------------------------------------------------------------------------
14-gingival abnormalities
15-bleeding
16-35 mg
17- smoking
18-not determined
19-free radicals
20-cataracts
Page 422
Part B
1. C
2. B
3. B
4. A
5. B
6. A
Part C.1
1. B
2. C
3. A
4. B
5. C
6. D
7. C
8. B
Part C.2
1. A
2. D
3. A
4. B
5. D
6. C
7. B
8. A
Page 423
20
OET Online Test 6
Page 424
Dengue Fever: Texts
Text A
Dengue: virus, fever and mosquitoes
Dengue fever is a viral disease spread only by certain mosquitoes – mostly Aedes aegypti or
“dengue mosquitoes” which are common in tropical areas around the world.
There are four types of the dengue virus that cause dengue fever – Dengue Type 1, 2, 3 and 4. People
become immune to a particular type of dengue virus once they’ve had it, but can still get sick from the
other types of dengue if exposed. Catching different types of dengue, even years apart, increases the
risk of developing severe dengue. Severe dengue causes bleeding and shock, and can be life
threatening.
Dengue mosquitoes only live and breed around humans and buildings, and not in bush or rural areas.
They bite during the day – mainly mornings and evenings. Dengue mosquitoes are not born with
dengue virus in them, but if one bites a sick person having the virus in their blood, that mosquito can
pass it on to another human after about a week. This time gap for the virus to multiply in the mosquito
means that only elderly female mosquitoes transmit dengue fever. The mosquitoes remain infectious for
life, and can infect several people. Dengue does not spread directly from person to person.
Text B
Signs and Symptoms
Classic dengue fever, or “break bone fever,” is characterised by acute onset of high fever 3–14 days after
the bite of an infected mosquito. Symptoms include frontal headache, retro-orbital pain, myalgias,
arthralgias, hemorrhagic manifestations, rash, and low white blood cell count. The patient also may
complain of weight loss and nausea. Acute symptoms, when present, usually last about 1 week, but
weakness, malaise, and weight loss may persist for several weeks. A high proportion of dengue infections
produce no symptoms or minimal symptoms, especially in children and those with no previous history of
having a dengue infection.
Page 425
Dengue Fever: Texts
Text C
Steps to take when seeing a suspected case of dengue fever
Step 1: Notify your nearest Public Health Unit immediately upon clinical
suspicion.
Step 2: Take a comprehensive travel history and determine whether the

case was acquired overseas or locally.
Step 3: Note the date of onset of symptoms to identify the correct

diagnostic test, as suitable laboratory tests depend on when the blood
sample is collected during the illness.
• Another useful test is full blood count. Cases often have leukopenia
and/or thrombocytopenia.
The table below shows which test to order at which stage of illness:
TEST TYPE PCR NSI IgM IgG

ELISA
Days after
onset of 0-5 days 0-9 days From day 5 From day 8
symptoms onwards onwards
Step 4: Provide personal protection advice.
• The patient should stay in screened accommodation and have someone

stay home to look after them.
• The patient should use personal insect repellent particularly during

daylight hours to avoid mosquito bites.
• All household members should use personal insect repellent during

daylight hours.
• Advise family members or associates of the case who develop a fever

to present immediately for diagnosis.
Page 426
Dengue Fever: Texts
Text D
Prior to discharge:
• Tell patients to drink plenty of fluids and get plenty of rest.
• Tell patients to take antipyretics to control their temperature. Children with dengue are at risk for
febrile seizures during the febrile phase of illness.
• Warn patients to avoid aspirin and anti-inflammatory medications because they increase the risk of
haemorrhage.
• Monitor your patients’ hydration status during the febrile phase of illness. Educate patients and parents
about the signs of dehydration and have them monitor their urine output.
• Assess hemodynamic status frequently by checking the patient’s heart rate, capillary refill,
pulse pressure, blood pressure, and urine output. If patients cannot tolerate fluids orally, they may need
IV fluids.
• Perform hemodynamic assessments, baseline hematocrit testing, and platelet counts.
• Continue to monitor your patients closely during defervescence. The critical phase of dengue begins
with defervescence and lasts 24–48 hours.
END OF PART A
Page 427
TEST 6
A6
Question 1-7
1) the different types of dengue virus? _______

2) how fever presents in patients? _______
3) how dengue fever is transmitted? _______
4) the stages at which to conduct tests for dengue fever? _______
5) monitoring and assessing a patient’s condition? _______
6) what advice to give patients to avoid mosquito bites? _______
7) advice for patients regarding medication? _______
8- How long after being bitten by an infected mosquito does high fever occur?
______________________________________________
9-What might patients with dengue fever complain of?
______________________________________________
10-Which test should only be ordered 5 days after symptoms appear?
______________________________________________
11-What other test is also useful when checking for dengue fever?
______________________________________________
12-Who is at risk of seizures during the febrile stage of dengue?
______________________________________________
13-What takes places in the most lethal cases of dengue?
______________________________________________
14-How long does the most serious stage of dengue last?
______________________________________________
Page 428
15- Dengue fever does not spread ______________.
16- In many _____________dengue infections cause almost no symptoms.
17-Within three days of symptoms beginning a PCR or _____________can be ordered.
18- To avoid haemorrhage patients mustn’t take anti-inflammatory medications

or _____________.
19- Advise patients be cared for by someone at home

in _____________accommodation.
20- Patients must be made aware of the need to check their _____________.
Page 429
B6
Page 430
Page 431
Page 432
C6.1
Page 433
____________
Page 434
Page 435
C6.2
Page 436
Page 437
Page 438
Page 439
OET ONLINE TEST 6
ANSWER
----------------------------------------------------
Part A
1. A
2. B
3. A
4. C
5. D
6. C
7. D
----------------------------------------------------------------
8. 3-14 days
9. Weight loss and nausea
10. IgM
11. Full blood count
12. Children
13. Bleeding and shock
14. 24-48 hours
-----------------------------------------------------------------
15. Directly (from person to person)
16. Children
17. NSI ELISA (NS1 ELISA)
18. Aspirin
19. Screened
20. Urine output
Page 440
Part B
1. B
2. B
3. A
4. C
5. C
6. A
Part C.1
1. B
2. C
3. D
4. A
5. D
6. C
7. A
8. D
Part C.2
1. D
2. B
3. C
4. A
5. D
6. A
7. A
8. D
Page 441
21
IRS Test 1
Page 442
Reading test
Variations in HIV testing: Texts
Text A
What is an ELISA?
An ELISA or enzyme-linked immunosorbent assay, is a method used in the laboratory to aid in the diagnosis
of a wide range of diseases. This test is performed on blood or urine and is used for measuring the amount
of a particular protein or substance in these bodily fluids, such as infectious agents, allergens, hormones or
drugs.
This test relies on the interaction between components of the immune system called antigens and antibod-
ies. Antibodies are proteins produced by the body to identify and neutralise any foreign substances that may
be encountered, such as viruses and bacteria. The substances to which antibodies are produced are known
as the antigens as they stimulate an immune response.
What is the test used for?
ELISAs are used for numerous types of tests in the laboratory which can assist in the diagnosis of many
different conditions.
It is most commonly requested if it is suspected you have been exposed to viruses such as HIV and Hepatitis
B or C, or bacteria and parasitic infections such as Toxoplasmosis, Lyme disease and Helicobacter pylori. It
can also measure levels of antibodies to see if you have been vaccinated against certain diseases such as
mumps and rubella.
Other uses of the ELISA include:
• Measuring certain hormone levels such as HCG in the pregnancy test, thyroid hormones
• Detecting dust and food allergies
• Detection of illicit drugs such as cocaine and methamphetamines.
• Measuring antibodies which are produced in auto-immune conditions such as Lupus and rheuma-
toid arthritis.
Some kits are also available for the general public to use for example; the home pregnancy test is based on
the ELISA principle and detects the presence of a hormone known as human chorionic gonadotrophin (hCG)
which is excreted in the urine of a pregnant woman.
Study guide for OET © IRS Group 2018
Page 443
Text B
How accurate are different types of HIV tests?
Modern HIV tests are extremely accurate. There are a variety of different HIV tests and your healthcare worker
should explain which test you will be given and how you will get your result. Normally, testing involves taking a
small sample of blood from either your finger or your arm, or a sample of oral fluid.
How long an HIV test takes to give you an accurate result depends on the type of test you are taking. If you are
taking a rapid test, you will be given your results within 20 minutes. Other types of tests will be sent to a
laboratory and you may have to wait for the result which may take between a few days to a few weeks for you
to receive a final result.
Study guide for OET © IRS Group 2018 21
Page 444
Text C
Baseline risk-assessment
How to identify those at risk of HIV
PrEP is indicated for those at greater risk of HIV acquisition and therefore comprehensive history taking and
risk assessment, including both sexual and drug taking histories, are required to identify those most likely to
benefit.
Clinicians will need to make pragmatic decisions with patients about future HIV risk, their need for PrEP and
individual-level assessment of the benefit versus potential harms of PrEP. At a population level, given limited
resources and a desire to achieve the maximum impact of PrEP, clinicians should use clinical criteria and
recommendations as outlined in these guidelines, along with local and national criteria for NHS or clinical
trial eligibility to provide PrEP to those at highest risk of HIV acquisition.
It is well recognised that there are other risk behaviours and vulnerability factors that increase the risk of HIV
acquisition and these should be taken into consideration on a case-by-case basis by clinicians when
considering eligibility for PrEP and assessing HIV risk. Although this lacks a clear evidence base, the writing
group has considered this in terms of those who are ‘high risk’, and therefore PrEP would be recommended,
Page 445
Text D
Summary table of recommendations for PrEP
Recommend PrEP
(i) HIV-negative MSM and trans women who report condomless anal sex in the previous 6 months and on-
going condomless anal sex.
(ii) HIV-negative individuals having condomless sex with partners who are HIV positive, unless the partner
has been on ART for at least 6 months and their plasma viral load is <200 copies/mL.
Consider PrEP on a case-by-case basis
PrEP may be offered on a case-by-case basis to HIV-negative individuals considered at increased risk of HIV
acquisition through a combination of factors that may include the following:
Population-level indicators Clinical indicators

• Heterosexual black African men and women • Rectal bacterial STI in the previous year
• Recent migrants to the UK • Bacterial STI or HCV in the previous year
• Transgender women • Post-exposure prophylaxis following sexual expo-
• People who inject drugs sure (PEPSE) in the previous year; particularly
where repeated courses have been used
• People who report sex work or transactional sex
Sexual behaviour/sexual-network indicators Drug use

• High-risk sexual behaviour: reporting condomless • Sharing injecting equipment
sex with partners of unknown HIV status, and • Injecting in an unsafe setting
particularly where this is condomless anal sex or
• No access to needle and syringe programmes or
with multiple partners
opioid substitution therapy
• Condomless sex with partners from a population
group or country with high HIV prevalence
Sexual health autonomy
• Condomless sex with sexual partners who may fit
Other factors that may affect sexual health autonomy
the criteria of ‘high risk of HIV’ detailed above
• Inability to negotiate and/or use condoms (or
• Engages in chemsex or group sex
employ other HIV prevention methods) with sexual
• Reports anticipated future high-risk sexual
partners
behaviour
• Coercive and/or violent power dynamics in relation-
• Condomless vaginal sex should only considered
ships (e.g. intimate partner/domestic violence)
high risk where other contextual factors or vulner-
• Precarious housing or homelessness, and/or other
abilities are present
factors that may affect material circumstances
• Risk of sexual exploitation and trafficking
Page 446
Part A
Time: 15 minutes
Look at the four texts, A-D, in the separate Text Booklet.
For each question, 1-20, look through the texts, A-D, to find the relevant information.
Answer all the questions within the 15-minute time limit. Your answers should be correctly spelt.
Variations in HIV testing: Questions
Questions 1-7
For each of the questions 1-7, decide which text (A,B, C or D) the information comes from. You may use any
1. Time taken to receive 4th generation antigen tests ________________________________
2. Factors that are observed to affecting sexual autonomy ________________________________
3. The differing conditions that are diagnosed with ELISA test ________________________________
4. Talking to patients about pragmatic decisions on future ________________________________
5. Antibodies are the substances produced for antigens ________________________________
6. PrEP for partners from a high HIV risk population group ________________________________
7. Health care worker should explain the test given ________________________________
Questions 8 - 13
Answer each of the questions, 8 – 13, with a word or short phrase from one of the texts. Each answer may
8. What does an ELISA test measure for in pregnancy?
___________________________________________________________________________
9. How is acquisition considered for HIV negative individuals?
___________________________________________________________________________
10. How long does it take to receive results of a rapid test?
___________________________________________________________________________
11. What are the examples of autoimmune conditions detected by ELISA?
___________________________________________________________________________
Page 447
12. What kind of histories are required to identify those who need PrEP ?
___________________________________________________________________________
13. How long will it take to detect HIV with self-testing kits?
___________________________________________________________________________
Complete each of the sentences, 14 – 20, with a word or short phrase from one of the texts. Each answer may
14. Particular _________________________________________ are measured for diagnosis of an ELISA test.
15. People who engage in _________________________________________ sex falls under population level indicators.
16. HIV tests involve taking sample from _________________________________________ or the arm for detailed blood study.
17. _________________________________________ for PrEP must be considered on the basis of vulnerability factors for HIV.
18. Interaction between components of _________________________________________ is relied on for ELISA test results.
19. _________________________________________ of self testing kits is satisfactory but requires further medical scrutiny.
20. Individuals who have _________________________________________ with HIV positive partners must be recommended
PrEP.
Page 448
Part B
In this part of the test, there are four short extracts relating to the work of health professionals. For questions
1-6, choose the answer (A, B or C) which you think fits best according to the text.
1. The changes in standards as per the revised protocol was necessitated due to
A more evidence of associated risks seen

B inconsistent responses to new findings
C protocols that prioritize peadiatricians only
Executive Summary
Intravenous fluids are important components of appropriate care for hospitalised children. Reports in the
medical literature and warnings issued in other countries have highlighted the risks associated with use of
low sodium content fluids. The importance of appropriate glucose content has also been identified, and
emerging evidence suggests risks associated with high chloride. Individual or facility based responses to
the changing literature, along with the interim recommendations of a national expert group convened under
the auspices of Children’s Healthcare Australasia (CHA), have led to variable practices across NSW Health
hospitals with consequent inconsistencies and risks. The NSW Chief Paediatrician was tasked to engage
clinical experts, HealthShare and a range of other partners in the development of statewide standards
across all NSW facilities. The resultant Standards for Paediatric IV Fluids: NSW Health addresses fluid
content, bag size, labelling, administration, procurement and storage. A succinct Statement of the Stan-
dards presents the key messages and related actions on a single page.
Page 449
2. The guidelines on CDCT aims to enumerate the
A importance of eliciting personal preference

B morbidity rates noticed in clinical observations
C conservative estimates of procedural effectiveness
Updates on early lung cancer detection with Low-Dose Helical

Computed Tomography
Key Discussion Points for the Process of Shared Decision Making Related to Screening for Early Lung
Cancer Detection With Low-Dose Helical Computed Tomography
• Benefit: Screening with LDCT has been shown to substantially reduce the risk of dying from lung cancer
• Limitations: LDCT will not detect all lung cancers or all lung cancers early, and not all patients who have
a lung cancer detected by LDCT will avoid death from lung cancer
• Harms: There is a significant chance of a false-positive result, which will require additional periodic
testing and, in some instances, an invasive procedure to determine whether or not an abnormality is lung
cancer or some nonlung-related incidental finding; <1 in 1000 patients with a false-positive result expe-
riences a major complication resulting from a diagnostic workup; death within 60 d of a diagnostic
evaluation has been documented but is rare and most often occurs in patients with lung cancer
• Individuals who value the opportunity to reduce their risk of dying from lung cancer and who are willing
to accept the risks and costs associated with having an LDCT and the relatively high likelihood of the
need for further tests, even tests that have the rare but real risk of complications and death, may opt to
be screened with LDCT every year.
Page 450
3. The evaluation and management exercise requires students to
A perform in the presence of a billing physician

B document services accorded in the medical record
C record significant decision making exercises involved
Evaluation and Management Documentation Provided by Students

Any contribution and participation of a student to the performance of a billable service (other than review of
systems and/or past family/social history which are not separately billable, but are taken as part of an E/
M service) must be performed in the physical presence of a teaching physician or the physical presence of
a resident in a service that meets the requirements in this section for teaching physician billing. Students
may document services in the medical record; however, the teaching physician must verify in the medical
record all student documentation or findings, including history, physical exam, and/or medical decision
making. The teaching physician must personally perform (or re-perform) the physical exam and medical
decision making activities of the E/M service being billed and may verify any student documentation of
them in the medical record rather than re-documenting this work.
Page 451
4. On suspecting a disorder it is important to
A convey the gist of the problem

B articulate the symptoms with patient
C focus on associated illness outcomes
How to approach the consultation

• Adopt a non-judgmental approach through what is said and not said. Listen and understand the patient’s
version of reality, however bizarre it may appear, in order to discover more about what is going on in their
world
• Ask focused questions if psychosis is suspected and do not too readily dismiss symptoms as the results
of depression, anxiety, or substance misuse
• Avoid arguing with the patient—for example, by saying, “Of course there aren't devils under the bed.” It
works better to say, “I understand that this is how it appears to you, but this is how it appears to me”
• Be true to the person as they were when well. Remember hostility can be a symptom of the illness
• Avoid diagnostic labels at too early a stage; instead, focus the discussion around the patient’s symptoms
and experiences
• Avoid using stigmatising language. For example, some patients prefer “a person who experiences schizo-
phrenia” rather than “schizophrenic”
Page 452
5. The statutory catalogue informs
A appropriate dispensation of information is legal

B judicious consideration is required for data sharing
C consent of the individual must be maintained
Restricted sharing of information

There are circumstances where it is not permissible to make information publicly available, however it may
be permissible and appropriate to share that information with other organisations so that they may make
reasonable use of it. Such restricted sharing of information may include sharing information to support the
delivery of care for individuals, for managing systems of care for a population or for other purposes.
1. Under common law, any restricted sharing of information must not identify any individual unless
there is a legal means and purpose to do so. Permissible legal means will include cases when:
a. the person that the information is about has consented, or
2. b. there is a statutory basis for disclosure or court order, or
3. c. there is a public interest justification for disclosure, or
4. d. there is another basis in law for disclosure.
Page 453
6. The health guide advices individuals to
A prepare for long term wellness plan

B entrust a confidant for future care
C use informed choices for later care
Advance Care Planning

Advance care planning is a helpful way for people of all ages to prepare for the future. Both healthy people
and people with health conditions do advance care planning.
Advance care planning is:
• Making decisions now about the types of health care you would and would not want to receive if you
become very sick or injured and couldn’t speak for yourself in the future
• Choosing a person you want to make decisions for you if you’re unable to do so for yourself. This person
is called a health care agent
• Talking with your doctors and loved ones about the types of health care you want to receive so they’ll
respect and honor your values and health care goals
• Writing down your health care goals in MyCare, an advance directive. This form guides your health care
providers as to what types of health care you want. It also helps your loved ones understand your wishes
in case they have to make health care decisions for you
Page 454
Part C
answer (A, B, C or D) which you think fits best according to the text..
Text 1: Pancreatic cancer: gradual rise, increasing relevance
Pancreatic cancer is the 10th most frequently occurring cancer but the fifth most common cause of cancer
death in Australia, as is also seen in other developed regions of the world. A gradual increase in incidence has
been observed since the 1980s in almost all age groups in both sexes. Increases have been attributed only to
trends in smoking, which is considered causal, with local published data suggesting a lag of about 30 years
between smoking trends and incidence. However, being overweight and obesity may also have contributed, in
part, to incidence trends.
In developed countries, only about 50%–70% of cases of pancreatic cancer are histologically confirmed
based on review of the primary tumour, because pancreatic biopsy procedures have been associated with
significant risks and are often avoided. But improvements in imaging modalities, particularly endoscopic
ultrasound and pancreas-specific computed tomography, and magnetic resonance imaging protocols, together
with endoscopically guided biopsy procedures, are likely to have led to some of the increase in incidence
through improved detection.
In 2011, the latest year for which results are available, 5-year survival from pancreatic cancer was 5.2% in
Australia and 7.3% in the United States (among patients on selected Surveillance, Epidemiology and End
Results Program registers) with modest improvements observed over the past several decades. Five-year
survival from pancreatic cancer was about 3% in the mid1980s in both places. Between 1987 and 2007 in
Australia there was only a 6% drop in mortality from pancreatic cancer in both sexes (in those aged less than
75 years), compared with decreases in mortality of 34% from lung cancer, 47% from bowel cancer and 28%
from all cancers overall. Current projections suggest that within 10 years, pancreatic cancer will be the
second-highest cause of cancer death in the US as mortality and survival from the other four leading causes
of cancer death (lung, bowel, prostate, and breast cancers) improves. If these trends are reflected in Australia,
it would be anticipated that pancreatic cancer will become one of the leading causes of cancer mortality there
also.
Complete resection of the primary tumour currently offers the only hope of cure. Beyond the setting of high-
risk families, screening to identify precursor or early invasive lesions is not feasible for two main reasons.
First, endoscopic ultrasound is invasive and can only be used in specialised settings, so does not meet
criteria for a population screening test. Second, the positive predictive value of screening is limited by the low
population prevalence of pancreatic cancer. Attempts to categorise the population using known risk factors,
including several known single nucleotide polymorphisms, have not yet identified population subgroups at
sufficiently high risk to warrant screening.
Page 455
An avenue to optimise outcomes for patients is to ensure that all receive high-quality care in the most
appropriate setting. There is evidence from the US that not all patients with potentially resectable tumours are
offered surgery. Detailed data are not currently available for Australia, but it appears that there is similar
underutilisation of surgery there. It is thus important that all patients without metastatic disease are reviewed
by a multidisciplinary team in a major centre to determine the resectability of their pancreatic tumours. In
addition, it is of great consequence that resections be performed in hospitals that carry out a large number of
these procedures annually, as this has been shown to improve survival.
In conclusion, while the rise in pancreatic cancer incidence is slow, as the population ages, more people will
be affected with this disease. The burden of pancreatic cancer relative to other cancer types is likely to
increase. A multilevel approach is needed to control pancreatic cancer, including reducing the prevalence of
risk factors such as smoking and obesity, identifying effective biomarker screening tools and populations in
whom screening or early detection might be feasible, discovering new treatment modalities and ensuring that
all patients have access to optimal care.
Page 456
Text 1: Questions 7 - 14
7. Opinion gauged from paragraph one on the eighties is that
A a rise in pancreatic cancer has occurred in all age groups.

B the rate of pancreatic cancer has risen in most age groups.
C the rate of pancreatic cancer has swiftly risen in all groups.
D the rate of pancreatic cancer rose in almost all age groups.
8. For developing pancreatic cancer, it is suggested in paragraph 1 that ……
A smoking trends have been attributed as the key factor.

B smokers lag by thirty years behind the incidence and trends.
C smoking and obesity combined is the exclusive cause.
D smokers have to wait a timespan of 30 years to get cancer.
9. From paragraph 2, what is suggested on pancreatic biopsy procedures?
A historically risky, leading to a detection rate of 50 to 70%.

B often avoided which has led to a 50 to 70% confirmation rate.
C are usually avoided due to being too risky to ever undertake.
D have contributed to the microscopic amount of confirmation rates.
10. The improvements in technology as is mentioned in paragraph 2 ……
A have contributed little to detection rates of pancreatic cancer.

B have detected more incidences of pancreatic cancer.
C have led to the increase in early detection of most cancers.
D have detected the abrupt increase of pancreatic cancer.
Page 457
11. The word modest in paragraph 3 could NOT be replaced by ……
A Minor
B Marked
C Meagre
D Moderate
12. The figures for pancreatic cancer from the passage indicate
A a considerable decline in mortality rates for between 87-07.

B improved mortality rates within the next 10 years
C it will become the leading cause of cancer mortality.
D a highly probable rise in mortality rates in the near future.
13. In paragraph 4, the word ‘categorise’ could be replaced by
A Justify
B Classify
C Rectify
D Objectify
14. The author’s use of language in paragraph 6, is best described as ……
A Dismissive
B Biased
C Objective
D Disapproving
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Text 2: Role of oral health on overall well-being
The relationship between oral health and diabetes (Types 1 and 2) is well known and documented. In the last
decade, however, an increasing body of evidence has given support to the existence of an association between
oral health problems, specifically periodontal disease, and other systemic diseases, such as those of the
cardiovascular system. Adding further layers of complexity to the problem is the lack of awareness in much
of the population of periodontal disease, relative to their knowledge of more observable dental problems, as
well as the decreasing accessibility and affordability of dental treatment in Australia. While epidemiological
studies have confirmed links between periodontal disease and systemic diseases, from diabetes to autoimmune
conditions, osteoporosis, heart attacks and stroke, in the case of the last two the findings remain cautious
and qualified regarding the mechanics or biological rationale of the relationship.
Periodontal diseases, the most severe form of which is periodontitis, are inflammatory bacterial infections
that attack and destroy the attachment tissue and supporting bone of the jaw. Periodontitis occurs when
gingivitis is untreated or treatment is delayed. Bacteria in plaque that has spread below the gum line release
toxins which irritate the gums. These toxins stimulate a chronic inflammatory response in which the body, in
essence, turns on itself, and the tissues and bone that support the teeth are broken down and destroyed.
Gums separate from the teeth, forming pockets (spaces between the teeth and gums) that become infected.
As the disease progresses, the pockets deepen and more gum tissue and bone are destroyed. Often, this
destructive process only has very mild symptoms. Eventually, however, teeth can become loose and may
have to be removed.
The current interest in the relationship between periodontal disease and systemic disease may best be
attributed to a report by Kimmo Mattila and his colleagues. In 1989, in Finland, they conducted a case-control
study on patients who had experienced an acute myocardial infarction and compared them to control subjects
selected from the community. A dental examination was performed on all of the subjects studied, and a dental
index was computed. The dental index used was the sum of scores from the number of carious lesions,
missing teeth, and periapical lesions and probing depth measures to indicate periodontitis and the presence
or absence of pericoronitis (a red swelling of the soft tissues that surround the crown of a tooth which has
partially grown in). The researchers reported a highly significant association between poor dental health, as
measured by the dental index, and acute myocardial infarction. The association was independent of other risk
factors for heart attack, such as age, total cholesterol, high-density lipoprotein triglycerides, C peptide,
hypertension, diabetes, and smoking.
Since then, researchers have sought to understand the association between oral health, specifically periodontal
disease, and cardiovascular disease (CVD) – the missing link explaining the abnormally high blood levels of
some inflammatory markers or endotoxins and the presence of periodontal pathogens in the atherosclerotic
plaques of patients with periodontal disease. Two biological mechanisms have been suggested. One is that
periodontal bacteria may enter the circulatory system and contribute directly to atheromatous and thrombotic
processes. The other is that systemic factors may alter the immunoflammatory process involved in both
periodontal disease and CVD. It has also been suggested that some of these illnesses may in turn increase
the incidence and severity of periodontal disease by modifying the body’s immune response to the bacteria
involved, in a bi-directional relationship.
Page 459
However, not only is ‘the jury out’ on the actual mechanism of the relationship, it also remains impossible to
say whether treating gum disease can reduce the risk of cardiovascular disease and improve health outcomes
for those who are already sufferers. Additional research is needed to evaluate disease pathogenesis. Should
the contributing mechanisms be identified, however, it will confirm the role of oral health in overall well-being,
with some implications of this being the desirability of closer ties between the medical and the dental professions,
and improved public health education, not to mention greater access to preventive and curative dental treatment.
In time, periodontal disease may be added to other preventable risk factors for CVD, such as smoking, high
blood cholesterol, obesity and diabetes.
Page 460
15. According to paragraph 1, periodontal disease is unknown to many Australians because ……
A dental treatment is no longer affordable.

B the problem has a high degree of complexity.
C information on dental problems is inaccessible.
D it is not as prominent as other dental issues.
16. ‘Epidemiological’ in the first paragraph is used to denote
A causative
B scientific
C plagiarised
D controlled
17. According to paragraph three, the 1989 study in Finland ……
A prompted further interest in the link between oral health and systemic disease.
B did not take into account a number of important risk factors for heart attacks.
C concluded that people with oral health problems were likely to have heart attacks.
D was not considered significant when it was first reported but is very major now.
18. The relationship between dental hygeine and heart attacks as is expressed in paragraph three is
A inconclusive
B coincidental
C evident
D inconsequential
Page 461
19. As per paragraph three, the dental index was primarily used to
A indicate whether periodontis was present

B assess the overall oral health of patients.
C establish whether pericoronitis was present.
D predict the onset of acute myocardial infarction.
20. According to paragraph four, the viewpoint expressed is that
A cardiovascular disease could actually exacerbate periodontal disease.

B periodontal disease could modify the body’s immune response.
C there is a bi-directional relationship between periodontal disease and bacteria.
D systemic factors may contribute directly to atheromatous processes.
21. If the processes by which gum disease affects CVD, there will be ……
A less need for doctors and dentists to work in conjunction.

B a reduced emphasis on other preventable risk factors for CVD.
C a concomitant link between smoking and periodontal disease.
D more support for dental care in the public health system.
22. The expression the jury (is) out in paragraph 5 means that a definitive conclusion is ……
A imminent.
B impossible.
C without any merit
D yet to be attained.
END OF READING TEST

Page 462
READING SUB-TEST 1
PART A: QUESTIONS 1 - 20
1 B
2 D
3 A
4 C
5 A
6 D
7 B
8 HCG / Human Chorionic Gonadotropin
9 combination of factors
10 20 minutes / twenty minutes
11 lupus and rheumatoid arthritis
12 sexual and drug taking (history)
13 3 months / three months (after exposure)
14 protein
15 transactional
16 finger
17 eligibility
18 immune system
19 reliability
20 condomless sex
Page 463
PART B: QUESTIONS 1 - 6
1 B inconsistent responses to new findings

2 C conservative estimates of procedural effectiveness
3 A perform in the presence of a billing physician
4 B articulate the symptoms with patient
5 A appropriate dispensation of information is legal
6 C use informed choices for later care
PART C: QUESTIONS 7 - 14
7 B the rate of pancreatic cancer has risen in most age groups.

8 A smoking trends have been attributed as the key factor.
9 B often avoided which has led to a 50 to 70% confirmation rate.
10 B have detected more incidences of pancreatic cancer.
11 B Marked
12 D a highly probable rise in mortality rates in the near future.
13 B Classify
14 C Objective
15 D it is not as prominent as other dental issues

16 A causative
17 A prompted further interest in the link between oral health and systemic disease
18 C evident
19 B assess the overall oral health of patients
20 A cardiovascular disease could actually exacerbate periodontal disease
21 D more support for dental care in the public health system.
22 D yet to be attained
Page 464
22
IRS Test 2
Page 465
Reading test
Tuberculosis: Texts
Text A
Tuberculosis
Tuberculosis is an infectious disease caused in most cases by a micro-organism called Mycobacterium tuber-
culosis. The micro-organisms usually enter the body by inhalation through the lungs. They spread from the
initial location in the lungs to other parts of the body via the blood stream, the lymphatic system, the airways or
by direct extension to other organs.
• Pulmonary tuberculosis is the most frequent form of the disease, usually comprising over 80% of cases. It is
the form of tuberculosis that can be contagious.
• Extra-pulmonary tuberculosis is tuberculosis affecting organs other than the lungs, most frequently pleura,
lymph nodes, spine and other bones and joints, genitourinary tract, nervous system, abdomen or virtually any
organ. Tuberculosis may affect any part of the body, and may even become widely disseminated throughout
the whole body.
Tuberculosis develops in the human body in two stages. The first stage occurs when an individual who is
exposed to micro-organisms from an infectious case of tuberculosis becomes infected and the second is
when the infected individual develops the disease.
Page 466
Text B
Diagnosis of tuberculosis
The most frequent symptoms of pulmonary tuberculosis are:

• persistent cough for 2 weeks or more: every patient presenting with this symptom should be desig-
nated a tuberculosis suspect;
• sputum production, which may be blood-stained (haemoptysis), shortness of breath and chest pain;
• loss of appetite and loss of weight, a general feeling of illness and tiredness, night sweats and fever.
Any patient presenting with any of these symptoms should be suspected of having tuberculosis. If the patient is,
or was, in contact with a patient with infectious tuberculosis, such a person is even more likely to be suffering
from tuberculosis. © IRS Group
Symptoms of extra-pulmonary tuberculosis depend on the organ involved. Chest pain from tuberculosis pleu-
risy, enlarged lymph nodes and sharp angular deformity of the spine are some of the presenting symptoms or
signs of extra-pulmonary tuberculosis.
Symptoms of extra-pulmonary tuberculosis depend on the organ involved. Chest pain from tuberculosis pleu-
risy, enlarged lymph nodes and sharp angular deformity of the spine are some of the presenting symptoms or
signs of extra-pulmonary tuberculosis.
Tuberculosis cases are most likely to be found among:

• patients who present themselves on their own initiative at a health facility with symptoms suggesting
tuberculosis;
• those (especially children and young adults) living in the same household with smear-positive pa-
tients;
• those infected with HIV;
• those found to have an abnormality that has the appearance of tuberculosis when a chest radiograph
has been taken for clinical investigation of a sick patient.
Confirmation of the diagnosis:

There are several tests available to diagnosis TB. some of these are:
• Mantoux Test: This involves injecting a small amount of tuberculin into the skin in the lower part of the
arm. Then the person must return after 48 to 72 hours to have a trained health care worker look at
their arm and examine for hard area or swelling
• TB culture Test : Culture test involve studying bacteria by growing them on different substances. Bacte-
ria are usually contained in a sputum sample taken from suspected person.
• Chest X-ray: If a person has had bacteria which have caused inflammation in the lungs, an abnormal
shadow may be visible on an X-ray.
Page 467
Text C
First line tuberculosis drugs and its dosage in adults
Drugs Daily dose Preparation Side effects

in mg/kg (range)
Isoniazid 4-6 Tablets(50,100,300 mg)

Aqueous IV/IM solution Burning sensation,
(100mg/ml) Vomiting,Jaundice,
Confusion
Rifampicin 8-12 Capsule(150,300mg) Anorexia, Nausea,

Aqueous IV solution Itching, Purpura,
shock
Pyrazinamide 20-23 Tablet(500 mg) Joint pain,

Jaundice,vomiting
Ethambutol 15-25 Tablet(100 and 400 mg) Visual Impairment
Streptomycin 12-18 IM Injection Dizziness
For drug-resistant TB, a combination of antibiotics called fluoroquinolones and injectable medications such as
amikacin, kanamycin or capreomycin are generally used for 20-30 months.
Text D
Tuberculosis: Lifestyle Management
• People with active TB disease should stay away from work and school until the doctor says it’s safe to return,
in order to avoid infecting others.
• Cover the mouth with a tissue when coughing and sneezing, then seal the tissue in a bag to throw it away.
• Make sure the patient’s room has adequate ventilation, so that the exhaled bacteria are carried away.
• People with active disease need to tell their doctor or health professionals about anyone they have had close
contact with, such as family, friends. © IRS Group
• Take all the medications on right time. If patient stop taking medications or skip some doses, the risk of
developing drug resistant TB is high.
Page 468
Part A
Time: 15 minutes
Tuberculosis: Questions
Questions 1-6

1. Measures to prevent the spread of disease ________________________________
in household setting
2. Indicators of the disease ________________________________
3. How tuberculosis advances in individals ________________________________
4. Patients under risk ________________________________
5. Investigations to be done ________________________________
6. Tuberculosis treatment after exposure ________________________________
7. Mode of transmission of tuberculosis ________________________________
Questions 7-14
8. Which is the drug used for TB skin test?
________________________________________________________________
9. What is the maximum dose of streptomycin per kilo of a patient’s weight?

________________________________________________________________
10. Which bacteria causes tuberculosis?

________________________________________________________________
11. How long does a patient have to take medication for drug-resistant TB?
________________________________________________________________
12. Which type of tuberculosis spreads from infected person to others?

________________________________________________________________
Page 469
13. What needs to be ensured to remove breathe out bacteria from a room?
________________________________________________________________
14. What threat follows the stoppage of TB medications?

________________________________________________________________
Questions 15-20
Complete each of the sentences, 15-20, with a word or a short phrase from one of the texts. Each answer may
15. The disease advances beyond the _____________________________ to affect various areas.
16. The signs of extra-pulmonary disease is based on the involved _______________________
17. Mantoux test checks for hard area and .

_____________________________
18. Inflammation of lungs as a result of presence of bacteria may be evident on ___________________________.
19. _____________________________ is suspected on patients who visit the health sector on their own interest.
20. Four-drug regimen falls under _____________________________ tuberculosis drugs.
END OF PART A
Page 470
Part B
1. The standard procedure for health surveillance must include
A tests that require biological monitoring

B formulation of tests for close scrutiny
C constant testing to check for irregularities
Health Surveillance
As part of the monitoring system, health surveillance should be undertaken if appropriate. The health of
employees exposed to hazardous substances can be affected through absorption into the body. The
absorption route can be inhalation, by ingestion, through the skin or a combination of these. When inside
the body the substances are metabolised. Metabolites can target various organs of the body which can
thereby be harmed. Health surveillance therefore requires biological monitoring. At its simplest this could
be a skin inspection ensuring no dermatitic changes have occurred as a result of exposure to an irritant,
through to lung function tests and urine, breath or blood analysis. The criteria used to decide which type of
surveillance is appropriate depend on whether a test is available. Tributyl tin oxide was once used as a
timber preservation treatment; however, it was not known how it was metabolized in the body and therefore
no appropriate test existed. The potential for it to cause harm could not be eradicated and, as many
occupational diseases have a long latency period - up to 40 years for asbestosis, for example - tributyl tin
oxide was withdrawn from use.
Page 471
2. The manual promotes ‘airborne precautions’ for the
A use of an elaborate plan to prevent any infection

B ease to monitor adherence of preventive methods
C strength of protection against communicable sickness
Airborne Precautions
Airborne precautions prevent transmission of infectious disease that are spread by airborne droplets (= 5
microns) that remain infectious and suspended in air for long periods of time over long distances and can
be widely dispersed by air currents. Airborne precautions include:
Private room with monitored negative pressure ventilation of 6-12 air exchanges per hour; airborne infec-
tion isolation room (AIIR) preferred © IRS Group
Discharge of air to the outside or HEPA-filtered before recirculation

Door and windows much be kept closed at all times
Respiratory protection (usually an N-95 mask) for susceptible persons must be worn prior to entering
room and removed after leaving room
Droplet mask on patient when leaving room if tolerated; follow respiratory hygiene/cough etiquette
Limit transport to essential purposes only
If possible, non-immune healthcare workers should not care for patients with vaccine-preventable air-
borne diseases
Page 472
3. The extract ails to give information about
A work practices that reduce the risk of injuries

B the need to specify and follow regulations at work
C the importance of risk assessment and control measures
The six pack

Six new sets of regulations were produced in response to the European Parilament Framework Directive.
These are
Management of health and safety at work
Manual handling operations © IRS Group
Personal protective equipment at work
Health and safety (display screen equipment)
Provision and use of work equipment
Workplace (Health, safety and welfare)
While each set of regulations focuses on specific aspects of the workplace, they all have a common
theme. They reinforce the need for risk assessment, introducing control meaures and follow-up monitoring
and review systems. However, for the first time the idea of a ‘competent person’ is introduced. The em-
ployer is required to appoint one or more competent persons to assist in undertaking the measures needed
to comply with the relevant statutory provisions. This person must be knowledgeable about the risks to
health and safety within that workplace.
Page 473
4. The extract conveys the need to
A develop patient-centred healthcare service skills

B adopt approaches to achieve excellence in practice
C inculcate skills required by practice developers
Characteristics, Qualities and Skills

Whilst the primary role and function of practice development is the promotion and facilitation of patient-
centred health care services within a department and organization, there had been little work undertaken
examining the systems and processes involved in achieving this. The importance of capturing was to be
clearer about the approaches taken to develop excellence in practice at different organizational levela and
in addition, differentiate the skills and activities inherent in those working in practice development that still
are predominantly nurses. Garbett & McCormack’s substantial study analysing the cocept of practice
development formed the basis for further description and postulation of the characteristics, qualities and
skills of practice developers that remains ongoing.
Page 474
5. What does the regulation outline?
A prevention of similar injuries to employees ahead

B reporting of grievous injuries for acknowledgement
C analysis of the incident and its proper redressal
The reporting of injuries

Employers are required to report to the HSE (or local authority for retail premises) certain injuries, diseases
or dangerous occurrences that have stemmed from work activities. The enforcing authority must be notified
immediately.
The aim of the regulations is to provide information to the HSE for epidemiological purposes. Analysis of the
information may suggest a pattern of disease or injury associated with a particular industry. Action can be
taken to establish the cause of the risk and its prevention. The HSE has also published literature that is
available for healthcare professionals on request.
Page 475
6. The extract on randomised control trials on HIV infers
A presence of foreskin is a major precipitating factor

B circumcision performed by certain devices are safe
C immune systems are weak in males are uncircumcised
Male circumcision and HIV infection

A randomized controlled trial is the gold standard for scientific studies, and three such trials conclusively
determined that male circumcision reduces female-to-male HIV transmission by about 60% Responding
to this evidence, in March 2007, the World Health Organization and UNAIDS issued recommendations on
male circumcision and HIV prevention. The primary target cells through which HIV enters the body are
immune system target cells with CD4 receptors, including Langerhans cells. These cells are present in
high density in the epithelium of the inner foreskin and are close to the surface . The highly vascularized
foreskin mucosa and the mucosa at the frenulum are prone to tearing and bleeding during intercourse.
These microinjuries allow easy entry of HIV into the bloodstream. Important note about device-based
surgical methods In 2013, the World Health Organization stated that the male circumcision devices it
prequalifies are efficacious, safe and acceptable as additional methods of male circumcision for HIV pre-
vention among healthy men. Providers who perform circumcisions using device-based surgical methods
should be appropriately trained and competent in these of the specific device.
Page 476
Part C
Text 1: “Miracle” jab makes fat mice thin
After a four-week course of treatment with a protein called ob, the fat simply falls off, leaving vastly overweight
mice slim, active and sensible eaters. If the protein has the same effect on people, it could be the miracle cure
millions have been waiting for. That, at least, is the theory. But sceptics warn that too little is known about the
way the human version of the ob protein works to be sure that extra doses would help people to lose weight.
But when the results of the tests were leaked last week, Amgen, the Californian biotechnology company
which owns the exclusive rights to develop products based on the protein, saw an overnight jump in its share
prices.
Last December, a team led by Jeffrey Friedman and his colleagues at the Howard Hughes Medical Institute at
the Rockefeller University, New York discovered a gene which they called ob. In mice, a defect in this gene
makes them grow hugely obese. Humans have an almost identical gene, suggesting that the product of the
gene – the ob protein – plays a part in appetite control. The ob protein is a hormone, which Friedman has
dubbed leptin. In April, Amgen, which is based in Thousand Oaks, California, paid the institute $20 million for
exclusive rights to develop products based on the discovery. Amgen will carry out safety tests on the protein
in animals next year, and hopes to begin clinical trials on people within a year.
The excitement began last week when the journal Science published the findings of three groups which have
been working on the protein. The results in obese mice with a defective gene that prevents them making the
protein were dramatic. Mary Ann Pelleymounter and her colleagues at Amgen gave obese mice shots of the
protein every day for a month. Those on the highest dose lost an average of 22 per cent of their weight. Before
treatment, these mice overate, had lower metabolic rates than normal, lower temperatures, and raised levels
of insulin and glucose in their blood” says Pelleymounter. “The protein brought all these back to normal
levels,” she says.
More significantly, in terms of the potential for a human slimming drug, the treatment also worked on normal
mice, which lost what little spare fat they had. They lost between 3 and 5 per cent of their bodyweight, almost
all of it in the form of fat, according to Pelleymounter. This is important because no one has identified a
mutation in the human ob gene that might lead to obesity, suggesting that whatever the cause of obesity, the
ob protein might still help people lose weight. Friedman and his team carried out similar experiments. In just
one month, their obese mice shed around half their body fat. In the average obese mouse, fat makes up about
60 per cent of body weight. Treated mice lost their appetite. Within a few days they were eating about 40 per
cent as much as untreated animals. Their fat practically melted away, falling to 28 per cent of their body
weight after a month. In normal mice, treatment reduced the amount of fat from an average of 12.22 per cent
of body weight to a spare 0.67 per cent.
Page 477
Friedman and Pelleymounter believe that the protein, which is produced by fat cells, regulates appetite. “We
think it’s something like a circulating hormone to tell the brain there are normal amounts of fat, or too much,
in which case the brain turns down your appetite,” says Pelleymounter. The experiments also show that
treated mice have an increased metabolic rate, suggesting that they burn fat more efficiently. Their appetites
decrease – and they are less sluggish, becoming as active as normal mice.
The third group of researchers from the Swiss pharmaceuticals company Hoffmann-La Roche, are more
sceptical about how significant the ob protein might be in treating obesity. From their studies, they conclude
that the protein is just one of many factors that control appetite and weight. “This is a very important signal,
but it’s one of several,” says Arthur Campfield, who led the team. Campfield doubts whether the ob protein
alone will have much effect in overweight humans. His team hopes to unravel the whole signalling system that
regulates weight, and is particularly keen to find the receptor in the brain that responds to the ob hormone.
Hoffman-La Roche, excluded by the Amgen licence deal from developing products based on the ob protein
itself, hopes to develop pills that interfere with the message pathways in appetite control.
Stephen Bloom, professor of endocrinology at London’s Hammersmith Hospital, agrees. “I think the work with
ob is a major advance, but we’ve not got the tablet yet. That will come when people have made a pill that
stimulates the ob receptor in the brain so it switches off appetite.” Even Pelleymounter at Amgen cautions
against overoptimism at this stage. “We don’t know whether it would be true that people would lose weight,
but you can predict from mice that it would have some positive effect,” she says. “However, I don’t think obese
people should hold out for this. They should carry on with their exercises and dieting.”
Page 478
7. The first paragraph puts forward to the reader that
A a protein treatment has caused mice to lose weight dramatically

B a protein treatment for mice cannot be adapted for use in humans
C scientists agree that a new protein treatment makes people lose weight
D a scientific method of making obese people slim has been developed
8. According to Friedman and his colleagues, the ob protein
A may be transformed from mice to humans

B may be a factor in appetite control
C is produced by the ob hormone
D is mainly found in obese mice
9. What according to paragraph two does dubbed refer to
A written
B named
C defined
D proved
10. A study by Mary Ann Pellymounter and her colleagues found that
A the ob protein caused subjects in the study to decrease their metabolic rate
B the ob protein cased people to lose about twenty percent of their weight
C a deficiency in the ob protein had caused obesity in the subjects
D a defective ob gene resulted in the production of the ob protein
Page 479
11. According to the Friedman and Pelleymounter studies, treatment with ob protein
A may be useful only for people with a defective ob gene

B may be useful for anyone who wants to lose weight
C is effective only on mice with a defective ob gene.
D will not be effective on people who want to lose weight
12. What does sluggish in paragraph five denote?
A strong
B lazy
C slow
D sick
13. The research from Hoffman-La Roche are less confident of the protein’s importance because
A it has not been trialled yet on human beings

B the trials done on mice were rather inconclusive
C it does not have a significant role in weight loss
D it is not the only factor involved in appetite control
14. In conclusion, the article suggests that
A a treatment for obesity in humans will be developed from the ob protein

B scientists will soon have more knowledge about the ob receptor in the brain
C the results of the study of mice will lead to weight loss pills for humans
D despite the results of the study of mice, the benefits for humans is unknown
Page 480
Text 2: The search for cholesterol-free fats
Butter, as anyone who has not been living in a cave for the past ten years has probably heard, contains a lot
of saturated fat, which increases the levels of cholesterol in the blood. Margarine, on the other hand, is made
from vegetable oils, which contain cholesterol-lowering polyunsaturated fat. So switching to a diet with only
vegetable fats should lower cholesterol levels, right? ‘Wrong,’ says Margaret A Flynn, a nutritionist at the
University of Missouri. When she performed the experiment with a group of 71 faculty members – switching in
both directions – she found that ‘basically it made no difference whether they ate margarine or butter.’ The
reason, according to a growing group of nutritionists, could be partially hydrogenated fats. Recent studies
suggest that such fats might actually alter cholesterol levels in the blood in all the wrong ways, lowering the
‘good’ high-density lipoprotein and increasing the ‘bad’ low-density lipoprotein.
Partially hydrogenated fats are made by reacting polyunsaturated oils with hydrogen. The addition of hydrogen
turns the oils solid, and some of their polyunsaturated fat is turned into trans monounsaturated fats.
Monounsaturated fat is generally perceived as good, but things are not so simple. ‘Trans monounsaturates
act in the body like saturated fats,’ says Fred A Kummerow, a food chemist at the University of Illinois at
Urbana-Champaign. ‘Almost all naturally occurring monounsaturated fat is of the cis variety, which is more
like polyunsaturated fat.’ Flynn’s study is not the first to raise questions about trans fatty acids. Ten years
ago a Canadian government task force noted the apparent cholesterol-raising effects of trans fats and requested
margarine manufacturers to reduce the amounts – which can easily be done by altering the conditions of the
hydrogenation reaction.
Last August two Dutch researchers, Ronald P Mensink and Martijn B Katan, published a study in the New
England Journal of Medicine that showed eating a diet rich in trans fats increased low-density lipoprotein and
decreased levels of high-density lipoprotein. In an editorial accompanying the study, Scott M Grundy, a lipid
researcher at the University of Texas Southwestern Medical Center at Dallas, wrote that the ability of trans
fatty acids to increase low-density lipoprotein ‘in itself justifies their reduction in the diet.’ Grundy called for
changes in labelling regulations so that cholesterol-raising fatty acids, including trans monounsaturates, are
grouped together. James I Cleeman, co-ordinator of the National Cholesterol Education Program, disagrees.
‘To raise a red flag is premature,’ he says. ‘Mensink’s audience is the research community – the public
needs useable simplifications.’ Cleeman points out that the subjects in Mensink and Katan’s study ate
relatively large amounts of trans fats. He believes more typical consumption levels should be investigated
before any change in recommendations is warranted.
Furthermore, Cleeman notes that studies like Flynn’s are hard to interpret because subjects were allowed to
eat as they pleased. Flynn’s study, published this month in the Journal of the American College of Nutrition,
found considerable variability among subjects in their blood lipid profiles. ‘The only way to study the question
properly is in a metabolic ward,’ Cleeman says. ‘Trans fats are a wonderful example of an issue that’s not
ready for prime time.’ Edward A Emken, a specialist on trans fats at the Agricultural Research Service in
Peoria, Illinois, also downplays the concern but for different reasons. Although Mary G Enig, a nutritional
researcher at the University of Maryland, has estimated American adults consume 19 grams of trans fat per
day, Emken thinks that figure is too high. According to his calculations, eliminating trans fatty acids from the
Page 481
diet will for most people make only a tiny change in lipoprotein levels. ‘If you’re hypercholesterolaemic, it
could be important, but if you’re not, then it is not going to affect risk at all,’ he concludes.
Emken, together with Lisa C Hudgins and Jules Hirsch, has performed a study to be published in the American
Journal of Clinical Nutrition that finds no association between levels of trans fats in fat tissue in humans and
their cholesterol profiles. To Emken, that suggests trans fats are not a major threat for most people.
Nevertheless, trans fats seem destined for more limelight. ‘How can one defend having cholesterol and saturated
and unsaturated fats listed on food labels but not allow public access to trans information when such fats
behave like saturates?’ asks Bruce J Holub, a biochemist at the University of Guelph in Ontario. ‘At the very
least, one has to ask whether cholesterol-free claims should be allowed on high-trans products.’
Page 482
15. What is ‘wrong’ as made out from paragraph one?
A Switching to a diet with traditional vegetable fats

B Commonly held perception of polyunsaturated fat
C The method adopted by the experimental group
D available information regarding hydrogenated fats
16. M A Flynn’s finding is supported by the proposition that
A butter lowers high-density lipoprotein while margarine increases low-density lipoprotein

B butter contains just as much partially hydrogenated fat as margarine does
C trans monounsaturates behave similar to most naturally occurring monounsaturates
D trans monounsaturated fat increases the cholesterol level
17. The passage points out that
A eating butter is not as dangerous for cholesterol levels as was previously thought
B cholesterol levels in humans can be noticeably reduced by cutting out animal fats
C eating margarine is s healthier option than eating butter
D the benefits of using only vegetable fats in the human diet are arguable
18. In paragraph three, what is meant by ‘to raise a red flag’?
A to warn of dire consequences

B to criticize existing methods
C to express unfounded concern
D to ignore prevalent signs
Page 483
19. James I Cleeman is stated to
A agree with Grundy’s recommendation for relabelling

B dispute Mensink and Katan’s research into the effects of eating trans fats
C want Mensink and Katan’s work discussed outside the research community
D want to wait any longer before warning the public
20. Cleeman is of the view that
A Flynn’s study is not very valuable because she is hard to understand

B trans fats should now be discussed and debated by interested members of the public
C Flynn’s study was not sufficiently rigorous
D Flynn’s subjects should have had more food of a more vaied nature
21. On American consumption of trans fats, Edward Emken
A believes that a reduction in this figure could be achieved quite easily

B is not very concerned about trans fat intake levels for most people
C does not think that they should consume so much in trans fats
D thinks that people should eliminate trans fats from their diets
22. The passage summarises that,
A Emken, in a study published has challenged other researchers’ claims

B the levels of trans fats tissue in humans and their cholesterol profiles are not connected
C the issue of trans fat is likely to receive more, rather than less, attention in future
D food products should be labelled with their trans information in addition to current information
END OF READING TEST

Page 484
READING SUB-TEST 2
1 D
2 B
3 A
4 B
5 B
6 C
7 A
8 tuberculin
9 18 mg
10 myobacterium tuberculosis
11 20 - 30 months
12 pulmonary tuberculosis
13 (adequate) ventilation
14 drug resistant TB
15 lungs
16 organ
17 swelling
18 X ray
19 tuberculosis
20 first line
168 Study guide for OET © IRS Group 2018
Page 485
1 B formulation of tests for close scrutiny

2 B ease to monitor adherence of preventive methods
3 B the need to specify and follow regulations at work
4 C inculcate skills required by practice developers
5 A prevention of similar injuries to employees ahead
6 A presence of foreskin is a major precipitating factor
7 A a protein treatment has caused mice to lose weight dramatically

8 B may be a factor in appetite control
9 B named
10 C a deficiency in the ob protein had caused obesity in the subjects
11 B may be useful for anyone who wants to lose weight
12 C slow
13 D it is not the only factor involved in appetite control
14 D despite the results of the study of mice, the benefits for humans is unknown
15 B Commonly held perception of polyunsaturated fat

16 D trans monounsaturated fat increases the cholesterol level
17 D the benefits of using only vegetable fats in the human diet are arguable
18 C to express unfounded concern
19 A agree with Grundy’s recommendation for relabelling
20 C Flynn’s study was not sufficiently rigorous
21 B is not very concerned about trans fat intake levels for most people
22 C the issue of trans fat is likely to receive more, rather than less, attention in future
Page 486
23
IRS Test 3
Page 487
Reading test
Deep Vein Thrombosis : Texts
Text A
Descriptors
Deep vein thrombosis occurs when a blood clot (thrombus) forms in one or more of the deep veins in the
body, usually in the legs. It can cause leg pain or swelling, but may occur without any symptoms. Deep vein
thrombosis is a serious condition because blood clots in the veins can break loose, travel through the
bloodstream, and obstruct the lungs, blocking blood flow. Although it usually affects the leg veins, DVT can
occur in the upper extremities, cerebral sinuses, hepatic, and retinal veins.
Common symptoms include pain, especially throbbing cramp like feeling, swelling and tenderness in one of
your legs (usually your calf), a heavy ache in the affected area, warm skin in the area of the clot, red skin,
particularly at the back of your leg below the knee.
Text B
Causes of Deep Vein Thrombosis

Anyone can develop DVT, but it becomes more common in those with age above 40. As well as age, there
are also a number of other risk factors, including:
• having a history of DVT or pulmonary embolism
• having a family history of blood clots
• being inactive for long periods – such as after an operation or during a long journey
• blood vessel damage – a damaged blood vessel wall can result in the formation of a blood clot
• having certain conditions or treatments that cause your blood to clot more easily than normal –
such as cancer (including chemotherapy and radiotherapy treatment), heart and lung disease, thrombo-
philia and Hughes syndrome
• being pregnant – your blood also clots more easily during pregnancy
• being overweight or obese
The combined contraceptive pill and hormone replacement therapy (HRT) both contain the female hor-
mone oestrogen, which causes the blood to clot more easily. If taking either of these, the risk of develop-
ing DVT is slightly increased.
Page 488
Text C
Nursing Intervention for Deep Vein Thrombosis:
Various nursing intervention for deep-vein thrombosis are in the following:

1. Assess for and reports sign and symptoms of Deep Vein Thrombosis.
2. Keep the affected leg elevated and comfortable position.
3. Keep the head up of bed.
4. Immobilize the patient and initiate bed rest to reduce risk of clot mobilization.
5. Administer anticoagulants as ordered to reduce the risk of additional clotting.
6. Carefully calculate heparin dose.
7. Use infusion pump to administer intravenous heparin.
8. Do not mix the heparinized solution with other medications.
9. Discourage positions that compromise blood flow.
10. Administer analgesics (Morphine) as ordered to manage pain.
11. Apply warm compress to affected leg using a 2-hour-on, 2-hour-off schedule around the clock.
12. Provide elastic compression stocking as it not only increase blood flow, but also reduce swelling and
pain.
13. Administer oxygen as ordered in order to maintain tissue perfusion.
14. Check and monitor any sign of bleeding.
15. Check any sign of complication (Pulmonary embolism).
16. Obtain lab orders to monitor APTT, PT and INR.
17. Ensure intake of vitamin-k rich food including green, leafy vegetable.
18. Instruct patient to keep nasal mucosa hydrate and moist.
19. Ensure a minimum intravenous fluid intake of 2500ml per day for proper hydration unless contraindi-
cated to prevent increase blood viscosity.
20. Provide adequate knowledge to patient pertaining to warfarin therapy.
21. Check any sign of excessive bleeding complication of warfarin therapy.
22. Be aware of the signs of excessive bleeding, such as frequent and bilateral epitasis, hematuria (blood
in the urine) and deep tissue bruising (purpura).
23. Advise the patient to take care when brushing teeth in order to reduce risk of bleeding gums.
Page 489
Text D
Pharmacological Therapy
AMost DVT medications are anticoagulant drugs. Anticoagulants interfere with some part of the body’s
process that causes blood clots to form. This process is called the clotting cascade.
Newer anticoagulants
Drug name Brand name Oral pill or injectable solution
Apixaban Eliquis Oral
Dabigatran Pradaxa Oral
Dalteparin Fragmin Injectable
Edoxaban Savaysa Oral
Enoxaparin Lovenox Injectable
Fondaparinux Arixtra Injectable
Rivaroxaban Xarelto Oral
Two older anticoagulants used to help prevent and treat DVT are heparin and warfarin. If a patient takes
either of these drugs, the healthcare provider will need to monitor the patient often.
END OF PART A
Page 490
Part A
Time: 15 minutes
Deep Vein Thrombosis : Questions
Questions 1-7

1. Warning signs of deep vein thrombosis ________________________________
2. Hormone that increases the risk of DVT ________________________________
3. Definition for clotting cascade ________________________________
4. What does it feel when there is a blood clot ________________________________
5. Care for DVT patients ________________________________
6. Common drug regimen ________________________________
7. Factors that increase the danger of DVT ________________________________
Questions 8-14
8. What is the drug used for pain management?
________________________________________________________________
9. What is the complication of warfarin therapy?

________________________________________________________________
10. Which age group is at the risk of developing DVT more?

________________________________________________________________
11. What does the DVT pain feel like?

________________________________________________________________
12. Where does thrombus most commonly form?

________________________________________________________________
13. Which category does heparin and warfarin belong to?

________________________________________________________________
14. Which type of drugs are used to treat deep vein thrombosis?
________________________________________________________________
Page 491
Questions 15-20
15. Improving the flow of blodd and decreasing swelling and pain is the advantage of
_____________________________ .
16. The complication of DVT is _______________________
17. Blood clot obstructs the lungs and thereby block the _____________________________ .
18. The female hormone present in contraceptive pill and HRT is _____________________________ .
19. Injectable solution of dalteparin is available by the name ____________________________ .
20. Deep tissue bruising is termed as _____________________________ .
END OF PART A
Page 492
Part B
1. What is the primary purpose of obtaining a patient’s consent for the review?
A to give patients the liberty to participate or withdraw from the service

B to enable the accredited pharmacist to access relevant information
C to ensure that the information is safeguarded with security measures
Patient’s rights, confidentiality and consent

It is the consumer’s decision to participate in the Home Medicines Review (HMR) process and they may
elect to withdraw from the service at any time. Consent of the consumer is obtained by the GP when
initiating the HMR referral. The consent allows consumer information to be given to the accredited pharma-
cist conducting the HMR. All information gathered throughout the HMR service should be respected and
safeguarded acknowledging the consumer’s right to privacy and confidentiality. This includes all informa-
tion acquired in the course of providing the HMR service, exchanged with other health professionals,
discussed on the phone or in the pharmacy or stored as a result of the review. Confidentiality needs to be
maintained through the development of secure files (either electronic or in a secure filing cabinet). This
includes ensuring that any consumer information that is transmitted electronically uses encrypted or
secure electronic messaging to enhance security. At no time should consumer information be shared with
unauthorised people, relatives or other health care providers without the consent of the consumer or their
representative. Consumer consent needs to be obtained for medication reviews to be conducted and the
associated sharing of necessary information between health care providers. The HMR service provider
should confirm that appropriate consent has been obtained from the consumer before the HMR service is
commenced.
Page 493
2. What does the guideline try to regulate
A the number of hours of work permissible

B uneven working hours for different professions
C intensity of the work done in stipulated time
Working time regulations

As a general guide, these regulations state that workers cannot be forced to work for more than 48 hours
on average, and limits young workers’ hours to 8 hours a day or 40 hours a week. From 1 August 2018,
junior doctors’ hours will also be restricted. The number of hours should be averaged out over a 17-week-
period. Besides working time limits, the regulations cover working at night, health assessments for night
workers, time off, rest breaks at work and paid annual leave. There are provisions for workers to come to an
‘opt-out’ agreement with their employers for defined periods, should the nature of the work make this
necessary. These guidelines are governed by the Department of Trade and Industry and also the National
Health Service.
Page 494
3. The note emphasises the significance of the difference by
A indicating the contrasting purposes

B highlighting the informational value
C exhibiting the distinction in outcome
Aggregated versus disaggregated data

To ensure that services reach people in need and that no one is left behind, strategic information needs to
be usable in a way that helps the people, places and situations where interventions are needed. As building
blocks of strategic information, data can be combined or separated for different uses. Aggregated data are
combined from many sources (for example, client records, registers and surveys) and summarized for a
specific purpose, such as reporting or statistical analysis. When aggregated data are separated again
according to a specific variable they become disaggregated. Disaggregated data can inform decision-
making and planning so that interventions more effectively reach targeted groups.
Page 495
4. The standard procedure for health surveillance must include
A tests that require biological monitoring

B formulation of tests for close scrutiny
C constant testing to check for irregularities
Health Surveillance
As part of the monitoring system, health surveillance should be undertaken if appropriate. The health of
employees exposed to hazardous substances can be affected through absorption into the body. The
absorption route can be inhalation, by ingestion, through the skin or a combination of these. When inside
the body the substances are metabolised. Metabolites can target various organs of the body which can
thereby be harmed. Health surveillance therefore requires biological monitoring. At its simplest this could
be a skin inspection ensuring no dermatitic changes have occurred as a result of exposure to an irritant,
through to lung function tests and urine, breath or blood analysis. The criteria used to decide which type of
surveillance is appropriate depend on whether a test is available. Tributyl tin oxide was once used as a
timber preservation treatment; however, it was not known how it was metabolized in the body and therefore
no appropriate test existed. The potential for it to cause harm could not be eradicated and, as many
occupational diseases have a long latency period - up to 40 years for asbestosis, for example - tributyl tin
oxide was withdrawn from use.
Page 496
5. Needle stick injuries must be handled by
A following the laid out steps for complete care

B primarily completing any critical procedures
C exercising caution and refraining from routine
What to do if there is a needle-stick (sharps) injury
Despite best efforts, needle-stick (sharps) injuries do occur. The injured health care worker must balance
his/ her risks with the safety of the client. The following guidelines can help health care workers address
needlestick (sharps) injuries: As soon as it is safe to do so (with regard to client safety), the health care
worker with the needle-stick (sharps) injury should stop what he/she is doing, remove gloves, and wash
both hands and the area of the needle-stick (sharps) injury with soap and plenty of water. No antiseptics or
scrubbing brushes should be used. If the provider is in the middle of a procedure, then another qualified
provider should take over and complete the procedure. If no other qualified provider is present, then the
injured provider should ensure that any critical step is complete, wash both hands and the area of the
needle-stick injury, change gloves, and then complete the procedure. Should inform senior staff or manag-
ers at the clinic and follow clinic protocols for managing the needle-stick (sharps) injury.
Page 497
6. What does the circular convey?
A information on managing blood borne pathogens

B the policy implementation required for personnel
C preventative measures to reduce pathogenic risk
Managing Occupational Exposure To Blood Borne Pathogens,

Hepatitis And Hiv Through Post-Exposure Prophylaxis
Health care workers are at increased risk of accidental exposure to bloodborne pathogens—such as
hepatitis B and C viruses and HIV. A minimum approach to health and safety practices for health care
providers and waste workers includes the following:
• implementation of standardized management approaches
• compulsory vaccination for the hepatitis B virus for all health care workers, including cleaners and staff
who handle medical waste © IRS Group
• provision of sharps disposal boxes for safe disposal of used needles, syringes and other sharps •
compliance with hand hygiene standards
• availability of appropriate personal protective equipment—mask, face shield or goggles, rubber apron and
utility gloves (at the bare minimum, every health care worker handling waste should have a face shield and
utility gloves)
• appointment of a clinic staff member or designated staff to additional or dedicated responsibility for
infection control, including waste management
Immediately after any needle-stick (sharps) injury, the person injured should—as soon as it is safe to do
so—hand over his/her duties to another provider and wash the area with plenty of soap and water. Antisep-
tics or caustic agents, such as bleach, should not be used. Flush any exposed mucous membranes with
plenty of water. The clinic should have a system to quickly report any needle-stick (sharps) injuries to the
nearest health facility that provides post-exposure prophylaxis services so that this can be given to the
injured health care worker according to the national guidelines.
Page 498
Part C
Text 1: Non-invasive prenatal testing: the new era in reproductive medicine
In some countries, it is routine practice to offer pregnant women screening for foetal chromosomal and
structural abnormalities, and, if serious anomalies are diagnosed, the option of terminating the pregnancy.
Screening for chromosomal abnormalities commenced in the 1960s and was initially restricted to women
whose pregnancies were considered to be of increased risk because of an obstetric history of aneuploidy or
advanced maternal age. Over the past five decades, prenatal chromosome screening (PCS) has been expanded
to encompass the entire obstetric population. However, the commonly used aneuploidy screening tests are
plagued by high false-positive rates, typically 4%–5%. Confirmation of an increased screening risk for aneuploidy
involves diagnostic tests such as amniocentesis or chorionic villus sampling, each associated with low but
definite risks of pregnancy loss.
Many women are reluctant to proceed with a diagnostic test after a positive aneuploidy screening result, and
the ability to assess foetal genetic material without directly sampling the amniotic fluid or placenta has long
been a goal of prenatal diagnosis. The recent development of non-invasive prenatal testing (NIPT), a high-level
screening test using cell-free foetal DNA, offers the opportunity to markedly reduce the requirement for invasive
testing while potentially also increasing detection rates of chromosomal anomalies, in particular of trisomy
21. In addition, NIPT may be offered earlier in pregnancy than standard aneuploidy screening and diagnostic
techniques.
Although initially used in pregnancies at high risk for aneuploidy, recent data indicate that NIPT is also a
robust screening test in lower-risk pregnancies. NIPT is now the most sensitive and specific screening test for
the common trisomies, with detection rates greater than 99% for trisomy 21 and false-positive rates of less
than 0.5%. The performance characteristics for trisomies 13 and 18 and the sex chromosome anomalies are
lower than for trisomy 21, although the sensitivity is still typically greater than 90%.
NIPT is not without its limitations. Failure to obtain a result occurs in routine clinical practice in about 3%–4%
of tests, usually due to a low cell-free foetal DNA fraction, which is detectable in the maternal bloodstream,
typically because the sample was collected too early in the pregnancy or because of maternal obesity. False-
positive results have been associated with confined placental mosaicism, the death of a co-twin, maternal
malignancy and maternal mosaicism. Detection rates appear to be lower and the chances of not obtaining a
result are higher in twin than in singleton pregnancies.
Ethical questions, ever present and never fully resolved when discussing prenatal testing, will come more
sharply into focus with the broader introduction of NIPT into obstetric practice. A woman and her partner have
two options after trisomy 21 has been diagnosed: continuation or termination of the pregnancy. The option of
termination is widely regarded in our society as part of the couple's reproductive health rights. If the diagnosis
is made earlier, and termination methods that are less stressful and safer for the woman and more acceptable
to medical staff are available, there could be greater pressure to undergo testing (and termination, when
abnormalities are detected) than is currently the case.
Page 499
What message does this then send to people with trisomy 21 in our community and their families? The same
arguments would apply to other non-lethal chromosomal anomalies, such as Turner syndrome. Of even
greater consequence would be the ability to discover the sex of the foetus at an early stage. Sex-based
termination, widespread in some parts of Asia, is believed to be uncommon in developed countries, but this
situation could change were the sex known much earlier in pregnancy. The wider introduction of NIPT must be
accompanied by appropriate increases in the provision of genetic counselling services for women and of
education for health care providers.
Page 500
7. Paragraph one indicates that termination of pregnancy is
A commonly practised in some countries

B a possibility in some countries
C routine practice in most countries
D often carried out for serious anomalies
8. Prenatal chromosome screening has
A confirmed an increase in screening risk

B resulted in significant loss of fetal life
C been observed to be used in all pregnancies
D commonly shown an increased sign of abortion
9. Paragraph two concludes that NIPT may
A slightly lessen the requirement for invasive testing

B marginally increase requirement for invasive testing
C dramatically decrease the need for invasive testing
D significantly increase the need for invasive testing
10. Paragraph three suggests that for lower-risk aneuploidy detection
A NIPT is proving reliable for finding strong and durable lower-risk rates
B NIPT is considered to be a strong and reliable screening process
C NIPT is considered a significantly reliable robotic testing format
D NIPT mainly finds aneuploidy in lower-risk screening processes
Page 501
11. In paragraph four, it is assumed that carrying twins
A may lead to false-positive results, as can maternal mosaicism

B is included in the list of concerns involving false-positive readings
C gives a substantial drop in NIPT data of singleton pregnancies
D proves a greater risk in acquiring unreliable detection rates from NIPT
12. The phrase ‘will come more sharply into focus,’ in paragraph 5 means ethical questions
A will be visually clear and free from debate for all people.
B will become a topic of greater discussion and debate among people.
C will become a topic of much hostile criticism among the community.
D will rise quickly into focus and force complacency among the community
13. Which of the following best describes the author’s use of the term non-lethal in paragraph six?
A unimpressive
B dangerous
C unintentional
D nonnoxious
14. The final paragraph professes
A NIPT will cause sex-based termination to increase in developed countries.

B Counselling and education must be given prior to introducing NIPT.
C Sex-based termination is an obsolete problem throughout Asia.
D Education and counselling services should coincide with introducing NIPT
Page 502
Text 2: Caring means Curing
In the paediatric intensive care unit at the University of California San Francisco (UCSF) Medical centre, four
nurses are clustered around the bed of an unconscious 7-year-old Cambodian boy who was hit by a truck
several days earlier. A plastic respirator tube snakes out of his mouth, and other tubes and wires connect him
to IV drips, evacuation bags, and a series of monitors that provide second-by-second displays of his heart and
respiratory rhythms. His right leg, bent at the knee, is held up in traction. His face is so swollen that visitors
find it too grueling to stare for too long. He is sedated to shield him from what would be excruciating agony and
to stave off any further threat of injury.
Janet Craig, a nurse educator based in the paediatric intensive care unit is comforting the boy’s family as they
keep an anxious bedside vigil. As they talk, a sudden commotion diverts Craig’s attention. She rushes
towards the room of another patient, hastily explaining that this 17-year-old girl has been a frequent visitor to
the ICU. She was born with a congenital heart defect that has required a number of surgeries, and recently
she may have suffered a heart attack. Five days earlier surgeons had implanted a permanent pacemaker, but
also decided that a heart transplant would be necessary if she were to survive over the long term.
In such an hour of intense activity, and in the time she spends each day attending to complex cases such as
those in the ICU, Janet Craig, an intensive care nurse for over 14 years, tries her utmost to embody the very
heart of the nursing profession – that unique relationship between caring and curing. In hospitals and communities
throughout the world, nursing staff are treating not only the patient’s complex physical needs but their interlinked
emotional needs as well. While doctors focus on limb, heart, or lung, nurses carry out the medical regimens
that physicians prescribe, as well as monitoring intricate human needs.
Nurses take care of patients 24 hours a day, 7 days a week. If a patient with a broken leg complains of chest
pain, it is the nurse’s duty to inform the physician of a suspected pulmonary embolism. If a patient with
metastatic breast cancer comes in for chemotherapy and complains of dizziness, shivering, and simply not
feeling like herself, the nurse will alert the oncologist to the possibility that the cancer may have travelled to
the brain. In addition to following the physicians’ treatment plan, nurses establish treatment plans of their
own. They assess patients’ basic needs and do for them what they cannot do alone; they help educate
people about how to cope with a disease or the aftermath of surgery; they become deeply involved – as
patient advocates – in helping patients and families make informed decisions about major surgery and
termination of life-support systems. All of these responsibilities should make nurses major participants in the
evolving debate about national health care. Yet to most of the public and policy-makers, they remain almost
invisible.
Real health care involves far more than paying physicians to intervene when disease is well established or
financing dazzling research into potential ‘cures.’ It involves education in disease prevention and health
maintenance from childhood through old age, as well as providing skilled nursing care in hospitals when
patients are acutely ill. A truly humane system would not push futile treatment on patients with terminal
diseases, but would permit them to die in comfort and with dignity. A genuinely economical health-care
system would finance a cohesive network of long-term care to be provided outside of big hospitals in the home
and the community.
Page 503
To create a new health-care system, nurses need to be far more assertive in promoting their profession and its
achievements. They also need advocates and allies – among patients, families, politicians and businessmen
– who understand that high-quality health care is dependent not only on technology, surgery and the promise
of cure but also on the efforts of those nurses providing the care necessary for cure to be possible at all.
Page 504
15. In paragraph one, what is meant by the use of the word ‘clustered’?
A Anxious
B Silent
C Motionless
D Gathered
16. the use of sedatives as mentioned in paragraph one are
A given needlessly for the particular situation

B to immobilise him and numb the pain
C to prevent the respiratory tube from moving
D not needed as he is unconscious
17. The objective of nurse educator is to
A keep a bedside vigil with the patient’s relatives

B maintain a level of support befitting the situation
C take charge of the emergency situation taking place
D remedy the immediate danger to the 17-year-old-girl
18. In paragraph three, the author’s view is that
A doctors should solely treat the physical needs of the patient

B nurses only focus on the emotional and human needs of patients.
C nurses undergo a grueling regimen of physical prescriptions.
D doctors tend to deal with the physical aspects of the patient.
Page 505
19. According to paragraph four, current debates on health care have
A completely excluded nurses and their insight into the health industry.
B left policy-makers and the public no alternative but to exclude nurse
C evolved without proper input from nurses
D remained nearly invisible to policy-makers and the public
20. As per paragraph five, complete healthcare involves
A disease prevention and humane system

B providing funds for probable cure
C permitting people to die with dignity
D health education and skilled care
21. The opinion put forth by the final paragraph is that
A Confident nurses are unnecessary for a positive view of their profession.

B Nurses need politicians support for new technological advancements.
C The promise of cure does not guarantee successful surgeries.
D Nursing as a whole is as imperative as other dependent factors.
22. Which word can be best described for the term “futile” in paragraph five?
A expensive
B flashy
C needless
D unprofitable
END OF READING TEST

Page 506
READING SUB-TEST 3
1 A
2 B
3 D
4 A
5 C
6 D
7 B
8 morphine
9 bleeping
10 above 40
11 throbbing cramp
12 leg
13 older anticoagulants
14 anticoagulants
15 stockings
16 pulmonary embolism
17 blood flow
18 oestrogen
19 lovenox
20 purpura
Page 507
1 B to enable the accredited pharmacist to access relevant information

2 A the number of hours of work permissible
3 A indicating the contrasting purposes
4 B formulation of tests for close scrutiny
5 A following the laid out steps for complete care
6 C preventative measures to reduce pathogenic risk
7 B a possibility in some countries

8 C been observed to be used in all pregnancies
9 C dramatically decrease the need for invasive testing
10 B NIPT is considered to be a strong and reliable screening process
11 D proves a greater risk in acquiring unreliable detection rates from NIPT
12 B will become a topic of greater discussion and debate among people.
13 D nonnoxious
14 D Education and counselling services should coincide with introducing NIPT
15 D Gathered
16 B to immobilise him and numb the pain
17 B maintain a level of support befitting the situation
18 D doctors tend to deal with the physical aspects of the patient.
19 C evolved without proper input from nurses
20 D health education and skilled care
21 D Nursing as a whole is as imperative as other dependent factors.
22 D unprofitable
Page 508
24
IRS Test 4
Page 509
Reading test
Schizophrenia: Texts
Text A
Assess Symptoms and Establish a Diagnosis.
Establish an accurate diagnosis, considering other psychotic disorders in the differential diagnosis because of
the major implications for short- and long-term treatment planning. If a definitive diagnosis cannot be made but
the patient appears prodromally symptomatic and at risk for psychosis, evaluate the patient frequently.
Reevaluate the patient’s diagnosis and update the treatment plan as new information about the patient and his
or her symptoms becomes available. © IRS Group
Identify the targets of each treatment, use outcome measures that gauge the effect of treatment, and have
realistic expectations about the degrees of improvement that constitute successful treatment.
Consider the use of objective, quantitative rating scales to monitor clinical status (e.g., Abnormal Involuntary
Movement Scale [AIMS], Structured Clinical Interview for DSM-IV Axis I Disorders [SCID], Brief Psychiatric Rating
Scale [BPRS], Positive and Negative SyndromeScale [PANSS]).
Page 510
Text B
Assistance in Organising Confusing Experiences

ABC model
The ABC model, which was originally developed by Ellis and Harper,12 can be used to give the patient a
way of organizing confusing experiences. It involves slowly and thoroughly moving the patient through the
various steps using Socratic questioning to clarify the links between the emotional distress the patient is
experiencing and the beliefs he holds (Table). It includes the following steps:
• Based on a scale of 0 to 10, the patient rates the intensity of distress.
• The consequence (C) is assessed and divided into emotional and behavioral Cs.
• The patient gives his own explanation as to what activating events (As) seemed to cause C; and
the therapist ensures that the factual events are not “contaminated” by judgments and interpretations.
• The therapist provides feedback to the patient to acknowledge the A-C connection.
• The therapist assesses the patient's belief, evaluations, and images and communicates to the
patient that a personal meaning is lacking in the A-C model; simple examples can be provided to facilitate
understanding.
• The patient's own belief (B), which is actually the cause of C, is then discussed; often, this can
be rationalized, and a B such as “nobody will like me if I tell them about my voices” can be disputed and
changed to “I can't demand that everyone likes me. Some people will and some won't...Maybe some
friends might find it interesting.” This may lead to a change in C, ie, less sadness and isolation.
Page 511
Text C
Page 512
Text D
Goals of Treatment
• Minimize stress on the patient and provide support to minimize the likelihood of relapse.
• Enhance the patient’s adaptation to life in the community.
• Facilitate continued reduction in symptoms and consolidation of remission, and promote the process
of recovery.
If the patient has achieved an adequate therapeutic response with minimal side effects, monitor response
to the same medication and dose for the next 6 months.
Assess adverse side effects continuing from the acute phase, and adjust pharmacotherapy accordingly
to minimize them.
Continue with supportive psychotherapeutic interventions.
Begin education for the patient (and continue education for family members) about the course and out-
come of the illness and emphasize the importance of treatment adherence.
To avoid gaps in service delivery, arrange for linkage of services between hospital and community treat-
ment before the patient is discharged from the hospital.
For hospitalized patients, it is frequently beneficial to arrange an appointment with an outpatient psychia-
trist and, for patients who will reside in a community residence, to arrange a visit before discharge.
After discharge, help patients adjust to life in the community through realistic goal setting without undue
pressure to perform at high levels vocationally and socially.
Page 513
Part A
Time: 15 minutes
Schizophrenia: Questions
Questions 1-7
letter more than once. © IRS Group

1. Facilitating continued deduction in symptoms ________________________________
2. The various steps using socratic questioning ________________________________
3. Gauging the effect of treatment to establish diagnosis ________________________________
4. The rating scales used to monitor clinical status ________________________________
5. Administration routes © IRS Group for giving drugs ________________________________
6. Advantages of haloperidol medication for treatment ________________________________
7. Division into emotional and behavioural Cs ________________________________
Questions 8-14
8. What must be arranged for, to avoid gaps between hospital and community
________________________________________________________________
9. What was the ABC model developed to © IRS Group assist

________________________________________________________________
10. What does the therapist provide to acknowledge the A-C connection?
________________________________________________________________
11. What can be used to gauge the effect of treatment?

________________________________________________________________
12. What must be done if the patient appears problematically symptomatic?

________________________________________________________________
13. How long will a sublingual administration of asenapine take to peak plasma concentration?
________________________________________________________________
14. Which drugs are examples of slow acting orally disintegrating tablets?
________________________________________________________________
Page 514
Questions 15-20
15. A disadvantage of inhaled medication is that it requires _____________________________.
16. _____________________________ route of administration of midazolam ensures rapid absorption.
17. It is advised to _____________________________ the patient’s diagnosis and update the treatment plan.
18. The ABC Model helps to clarify _____________________________ from the beliefs the patient holds.
19. Assitance in understanding © IRS Group can be facilitated by providing ______________________ .
20. After discharge, patients must be allowed to perform without _____________________________.
Page 515
Part B
1. The extract from the circular is intended to
A. give information on compiling private prescriptions

B. remind the staff of particulars to be included
C. instruct the doctors of methods to standardise procedures
Record keeping
A record must be kept of every DCA EPP prescription only medicine (POM) supplied. Record to be kept in
a bound book or electronically.
• Particulars to be recorded:
— Date of supply
— Name, © IRS Group
quantity and pharmaceutical form and strength of the medicine
— Date on the prescription
— Name and address of the prescriber
— Name and address of the patient
• Entry must be made on the day of supply, or if that is not reasonably practical, on the next following day.
• The record must be retained for a period of 2 years from the date of last entry in the book/electronic register.
• Prescription token must be referenced accordingly and filed in a chronological order, and retained for a
period of 2 years from the date of supply.
Page 516
2. The report on homeless patients suggests that issues can be addressed by
A. assuring help required from a GP or dentist

B. registering the identity of those uncovered
C. adhering to the laid down structure of identification
The issues of looking after homeless patients in General

Practice
In 2014 Homeless Link reported that 90% of the homeless people they surveyed were registered with a
GP. However many responded that they were not receiving the help they needed for their health prob-
lems, and 7% had been refused access to a GP or dentist in the previous 12 months. In some cases
these refusals were due to having missed a previous appointment or because of behaviour. Others
reported that they were refused access if they did not have identification or proof of address. The Health
and Social Care Act introduced statutory duties on the health department to “have regard to the need to
reduce inequalities” in access to and outcomes achieved by services. Many practices request multiple
forms of identification and proof of address when registering new patients. This can be useful for them to
ensure identity and contact details. The General Medical Services Contracts Regulations state that
practices may only refuse an application to go on their list if they have reasonable grounds for doing so
which do not relate to the applicant’s race, gender, social class, age, religion, sexual orientation, ap-
pearance, disability or medical condition.
Page 517
3. What does this advisory intend to convey?
A. The requirement for monitor of malnourished patients.

B. Primary route for providing external nutritional support
C. Identification and management of malnourished patients.
Step to contain malnourishment
Malnutrition is a state in which a deficiency of energy, protein and/or other nutrients causes measurable
adverse effects on tissue/body form, composition, function or clinical outcome. It is vital to identify
patients at risk of malnutrition as nutritional support is advantageous in malnourished patients. A nutri-
tional screening tool can help identify the patient. A useful malnutrition Universal Screening Tool has
been developed by the Malnutrition Advisory Group.
Enteral nutrition should be the first-line route for the provision of nutritional support. If the gut works,
enteral feeding should be used. © IRS Group
Page 518
4. The directive on discharge plan outlines the
A. Approach to be considered on the length of the stay

B. Need for the patients choice in the duration of stay
C. Use of systems to estimate the course of admission
Discharge or transfer protocols update
Most patients want to know how long they are likely to stay in hospital, and to be provided with informa-
tion about their treatment and when they are likely to be discharged. This helps them achieve their goals
and plan for their own transfer. The exceptions to this are intensive care and high-dependency units,
where setting an expected date should be delayed until the patient is transferred to the ward. Predicting
a patient’s length of stay can be undertaken in two ways. It can be based on actual performance in the
ward or unit, or on benchmarking information. It is essential that the ward or unit understands and uses
the adopted system to give a valid and sustainable approach. The Department of Health’s discharge
guidance states that: “Estimated date of discharge is based on the expected time required for tests and
interventions to be completed, the integrated care pathway and the time it is likely to take for the patient
to be clinically stable and fit for discharge.”
Page 519
5. In the prospectus for infection prevention, what are control professionals required to do?
A. Prepare an exhaustive analysis and control an outbreak

B. Chart a course to apply policies that cuts an infection
C. Implement practices that are best suited for individuals
Infection prevention and control professional
A person whose primary training is in either nursing, medical technology, microbiology, or epidemiology
and who has acquired specialized training in infection control. Responsibilities may include collection,
analysis, and feedback of © IRS Group infection data and trends to healthcare providers; consultation
on infection risk assessment, prevention and control strategies; performance of education and training
activities; implementation of evidence-based infection control practices or those mandated by regulatory
and licensing agencies; application of epidemiologic principles to improve patient outcomes; participa-
tion in planning renovation and construction projects (e.g., to ensure appropriate containment of con-
struction dust); evaluation of new products or procedures on patient outcomes; oversight of employee
health services related to infection prevention; implementation of preparedness plans; communication
within the healthcare setting, with local and state health departments, and with the community at large
concerning infection control issues; and participation in research.
Page 520
6. In view of the circular published, what is the hospital trying to address
A. services required by the midwives for intensive care

B. support required for full term pregnant mothers
C. objectives that are vital for quality maternal care
Commitment and Support by Governing Body
In view of the necessity for Zamboanga City Medical Center

• to continuously control maternal death;
• to continuously provide quality and safe maternal care service; and
• to collaborate with the Department of Health on the control of maternal deaths to meet the Millenium
Development Goal,
the undersigned representing the governing body and top management of Zamboanga City Medical
Center hereby wholeheartedly commit to lead and to provide support in establishing and developing a
Maternal Death Control Management System in Zamboanga City Medical Center starting October 13,
2018. We also hereby authorize the Zamboanga City Medical Center Maternal Death Control Manage-
ment System Team to administer the program. This Manifestation of Commitment and Support by the
governing and top management by the Zamboanga City Medical Center shall be renewed every three
years.
Page 521
Text 1: The Chemistry and Physics Behind the Perfect Cup of Coffee
We humans seem to like drinks that contain coffee constituents (organic acids, Maillard products, esters and
heterocycles, to name a few) at 1.2 to 1.5 percent by mass (as in filter coffee), and also favor drinks containing
8 to 10 percent by mass (as in espresso). Concentrations outside of these ranges are challenging to execute.
There are a limited number of technologies that achieve 8 to 10 percent concentrations, the espresso machine
being the most familiar.
There are many ways, though, to achieve a drink containing 1.2 to 1.5 percent coffee. A pour-over, Turkish,
Arabic, Aeropress, French press, siphon or batch brew (that is, regular drip) apparatus – each produces
coffee that tastes good around these concentrations. These brew methods also boast an advantage over their
espresso counterpart: They are cheap. An espresso machine can produce a beverage of this concentration:
the Americano, which is just an espresso shot diluted with water to the concentration of filter coffee. There are
two families of brewing device within the low-concentration methods – those that fully immerse the coffee in
the brew water and those that flow the water through the coffee bed.
From a physical perspective, the major difference is that the temperature of the coffee particulates is higher in
the full immersion system. The slowest part of coffee extraction is not the rate at which compounds dissolve
from the particulate surface. Rather, it’s the speed at which coffee flavor moves through the solid particle to
the water-coffee interface, and this speed is increased with temperature.
A higher particulate temperature means that more of the tasty compounds trapped within the coffee particulates
will be extracted. But higher temperature also lets more of the unwanted compounds dissolve in the water,
too. The Specialty Coffee Association presents a flavor wheel to help us talk about these flavors – from green/
vegetative or papery/musty through to brown sugar or dried fruit. © IRS Group
The water-to-coffee ratio matters, too, in the brew time. Simply grinding more fine to increase extraction
invariably changes the brew time, as the water seeps more slowly through finer grounds. One can increase
the water-to-coffee ratio by using less coffee, but as the mass of coffee is reduced, the brew time also
decreases. Optimization of filter coffee brewing is hence multidimensional and trickier than full immersion
methods.
Every coffee enthusiast will rightly tell you that blade grinders are disfavored because they produce a seemingly
random particle size distribution; there can be both powder and essentially whole coffee beans coexisting.
The alternative, a burr grinder, features two pieces of metal with teeth that cut the coffee into progressively
smaller pieces. They allow ground particulates through an aperture only once they are small enough.
There is contention over how to optimize grind settings when using a burr grinder, though. One school of
thought supports grinding the coffee as fine as possible to maximize the surface area, which lets you extract
the most delicious flavors in higher concentrations. The rival school advocates grinding as coarse as possible
to minimize the production of fine particles that impart negative flavors. Perhaps the most useful advice here
is to determine what you like best based on your taste preference.
Finally, the freshness of the coffee itself is crucial. Roasted coffee contains a significant amount of CO2 and
other volatiles trapped within the solid coffee matrix: Over time these gaseous organic molecules will escape
the bean. Fewer volatiles mean a less flavorful cup of coffee. Most cafes will not serve coffee more than four
weeks out from the roast date, emphasizing the importance of using freshly roasted beans.
Page 522
7. The favorable concentration of drinks by mass in espresso include
A 3 percent by mass
B 8 percent by mass
C 12 percent by mass
D 1.3 percent by mass
8. What can be the advantage of other brew methods over espresso
A They produce a favorable concentration

B The methods are cheaper
C The other brew methods produce tastier coffee
D The other methods are advantageous
9. What can be the meaning of "counterpart"
A Neighbor
B Enemy
C Coequal
D Sibling
10. Higher temperature can help easy extraction even though
A More tastier compounds get trapped

B Unwanted compounds gets dissolved in the water
C The brewing gets trickier
D The speed gets increased with temperature
11. What can be true with respect to optimization of filter coffee brewing
A Water-coffee ration can be less of importance

B Full immersion methods gets less trickier and multidimensional
C Simple grinding does not changes brew time
D The relevance of optimization is null
Page 523
12. A burr grinder features
A Seemingly random particle size distribution

B Coexistence of powder and whole coffee beans
C A progressive grinding of coffee into smaller pieces
D Blade grinders are © IRS Group completely disfavored
13. What can be “contention”
A Approval
B Disagreement
C Harmony
D Plea
14. Less flavorful cup of coffee can be due to
A The gaseous organic molecules that escape the bean over time
B The volatiles that get trapped into the beans over time
C The freshly roasted beans have significant amount of CO2
D Cafes serve coffee that can be containing more volatiles
Page 524
Text 2: Difficult-to-treat depression
Depression remains a leading cause of distress and disability worldwide. In one country’s survey of health
and wellbeing in 1997, 7.2% of people surveyed had experienced a mood (affective) disorder in the previous 12
months. Those affected reported a mean of 11.7 disability days (when they were “completely unable to carry
out or had to cut down on their usual activities owing to their health”) in the previous 4 weeks. There was also
evidence of substantial under treatment: amazingly 35% of people with a mental health problem had a mental
health consultation during the previous 12 months. Of those with a mental health problem, 27% (i.e., three-
quarters of those seeking help) saw a general practitioner (GP). In the 2007–08 follow-up survey, not much
had changed: 12-month prevalence rates were 4.1% for depression, 1.3% for dysthymia and 1.8% for bipolar
disorder. These disorders were associated with significant disability, role impairment, and mental health and
substance use co-morbidity. Again, there was evidence of substantial unmet need, and again GPs were the
health professionals most likely to be providing care.
While general practitioners (GPs) have many skills in the assessment and treatment of depression, they are
often faced with people with depression who simply do not get better, despite the use of proven therapies, be
they psychological or pharmacological. This supplement aims to address some of the issues that GPs face
in this context. GPs are well placed in one regard, as they often have a longitudinal knowledge of the patient,
understand his or her circumstances, stressors and supports, and can marshal this knowledge into a coherent
and comprehensive management plan. Of course, GPs should not soldier on alone if they feel the patient is
not getting better.
In trying to understand what happens when GPs feel “stuck” while treating someone with depression, a
qualitative study was undertaken that aimed to gauge the response of GPs to the term “difficult-to-treat
depression”. It was found that, while there was confusion around the exact meaning of the term, GPs could
relate to it as broadly encompassing a range of individuals and presentations. Thus, the term has face validity,
if not specificity. More specific terms such as “treatment-resistant depression” are generally reserved for a
subgroup of people with difficult-to-treat depression that has failed to respond to treatment, with particular
management implications.
One scenario in which depression can be difficult to treat is in the context of physical illness. Depression is
often expressed via physical symptoms, but the obverse is that people with chronic physical ailments are at
high risk of depression. Pain syndromes are particularly tricky, as complaints of pain require the clinician to
accept them as “legitimate”, even if there is no obvious physical cause. The use of analgesics can create its
own problems, including dependence. Patients with comorbid chronic pain and depression require careful and
sensitive management and a long-term commitment from the GP to ensure consistency of care and support.
It is often difficult to tackle the topic of depression co-occurring with borderline personality disorder (BPD).
People with BPD have, as part of the core disorder, a perturbation of affect associated with marked variability
of mood. This can be very difficult for the patient to deal with, and can feed self-injurious and other harmful
behaviour. Use of mentalisation-based techniques is gaining support, and psychological treatments such as
dialectical behaviour therapy form the cornerstone of care. Use of medications tends to be secondary, and
prescription needs to be judicious and carefully targeted at particular symptoms. GPs can play a very important
role in helping people with BPD, but should not “go it alone”, instead ensuring sufficient support for themselves
as well as the patient.
Page 525
Another particularly problematic and well known form of depression is that which occurs in the context of
bipolar disorder. Firm data on how best to manage bipolar depression is surprisingly lacking. It is clear that
treatments such as unopposed antidepressants can make matters a lot worse, with the potential for induction
of mania and mood cycle acceleration. However, certain medications (notably, some mood stabilisers and
atypical antipsychotics) can alleviate much of the suffering associated with bipolar depression. Specialist
psychiatric input is often required to achieve the best pharmacological approach. For people with bipolar
disorder, psychological techniques and long-term planning can help prevent relapse. Family education and
support is also an important consideration.
Page 526
15. Paragraph one aims to convey that
A each surveyed participant in 1997 reported 11.7 disability days.

B those with an affective disorder performed their typical duties as normal.
C a large proportion of mental health consultations were provided by a GP.
D 35% having a mental health consultation is a great improvement.
16. What is signified from the statistics of 2007-2008?
A Comparable findings for the several mental illnesses mentioned.

B The rate of depression had fallen considerably.
C Disability days had declined from the 1997 statistics.
D The level of treatment provided had improved somewhat.
17. What information is expressed in paragraph two?
A GPs are in an advantageous position

B GPs should not force a pointless plan
C GPs must address the issues when faced
D GPs are likely to have required skills
18. According to paragraph 3, the term ‘difficult-to-treat depression’ has
A relatability to its broader meaning

B an unidentifiable and misunderstood meaning
C full value and is specific in its meaning
D full value but is not specific in its meaning
Page 527
19. Paragraph 4 implies that physical ailments are a difficult area because
A clinicians do not generally believe all apparent physical symptoms

B clinicians must decipher what is valid and what is improbable
C clinicians observe the patient for any legitimacy of mental problems
D clinicians only recognise legitimate complaints of comorbid chronic pain
20. According to paragraph 5, people with BPD s
A have a stable mood making it difficult to diagnose.

B have mood fluctuations which are key to the disorder.
C have rapid mood swings which are clearly identifiable.
D have limited support from the health service.
21. In paragraph 6, the author’s use of ‘surprisingly lacking’ is
A to portray a tone of doubt that it is truly lacking.

B because of the scarcity of bipolar disorder in modern times.
C due to the established prevalence of bipolar disorder.
D to enable readers to understand and feel the author’s skepticism.
22. Reducing symptoms associated with BPD is achieved by
A psychological techniques and long term planning

B treatments requiring unopposed antidepressant use
C medications including use of atypical antipsychotics
D therapies like family education and support groups
END OF READING TEST

Page 528
READING SUB-TEST 4
1 D
2 B
3 A
4 A
5 C
6 C
7 B
8 linkage of services
9 organising confusing experiences
10 feedback
11 outcome measures
12 evaluate frequently
13 0.5 to 1.5 hours
14 olanzapine, resperidone, aripoprazole
15 patient cooperation
16 itranasal
17 reevaluate
18 emotional distress
19 simple examples
20 undue pressure
Page 529
1 A give information on compiling private prescriptions

2 C adhering to the laid down structure of identification
3 C Identification and management of malnourished patients.
4 A Approach to be considered on the length of the stay
5 A Prepare an exhaustive analysis and control an outbreak
6 C objectives that are vital for quality maternal care
7 B 8 percent by mass
8 B The methods are cheaper
9 C Coequal
10 B Unwanted compounds gets dissolved in the water
11 B Full immersion methods gets less trickier and multidimensional
12 C A progressive grinding of coffee into smaller pieces
13 B Disagreement
14 A The gaseous organic molecules that escape the bean over time
15 C a large proportion of mental health consultations were provided by a GP.

16 A Comparable findings for the several mental illnesses mentioned.
17 A GPs are in an advantageous position
18 A relatability to its broader meaning
19 B clinicians must decipher what is valid and what is improbable
20 B have mood fluctuations which are key to the disorder.
21 C due to the established prevalence of bipolar disorder.
22 C medications including use of atypical antipsychotics
Page 530
25
IRS Test 5
Page 531
Reading test
Inguinal Hernia : Texts
Text A
Inguinal Hernia
An inguinal hernia is a protrusion of the intestine or bladder through the inguinal canal, often into the groin or
scrotum. It is a very common problem. The pain related to inguinal hernia worsen when coughing, exercising or
during bowel movements. The protrusion may not be visible, particularly in overweight patients, however, a
bulging area may occur in the area of the hernia, and may become markedly bigger when the patient is asked
to bear down.It is common among men than in women.
The cause of inguinal hernias depends on the type of inguinal hernia. The causes can range from mere birth
defects to the inclusion of external forces. Weakness within the abdominal wall, stress from bowel movements
or urination and activities such as lifting, exercising,sneezing, coughing, extensive weight gain create a hernia-
tion within the abdomen.
Page 532
Text B
Indirect versus direct inguinal hernias
© IRS Group
Direct inguinal hernia develop over time due to straining and is caused by weakness in abdominal
muscles whereas indirect hernia is caused by a defect in the abdominal wall.
Study guide for OET © IRS Group 2018 143
Page 533
Text C
How are inguinal hernias treated?

Repair of an inguinal hernia via surgery is the only treatment for inguinal hernias and can prevent incar-
ceration and strangulation. The two main types of surgery for hernias are
• Open hernia repair. During an open hernia repair, a health care provider usually gives a patient
local anesthesia in the abdomen with sedation; however, some patients may have
o sedation with a spinal block, in which a health care provider injects anesthetics around the
nerves in the spine, making the body numb from the waist down
o general anesthesia
• The surgeon makes a cut in the groin, moves the hernia back into the abdomen, and reinforces
the abdominal wall with stitches (herniorrhaphy). Usually the surgeon also reinforces the weak area
in abdominal wall with a synthetic mesh or “screen” to provide additional support (hernioplasty). This
procedure requires a single incision except in cases where hernias are on both sides.
• Laparoscopic hernia repair. A surgeon performs laparoscopic hernia repair with the patient under
general anesthesia. The surgeon makes several small, half-inch incisions in the lower abdomen and
inserts a laparoscope—a thin tube with a tiny video camera attached. The camera sends a magnified
image from inside the body to a video monitor, giving the surgeon a close-up view of the hernia and
surrounding tissue. While watching the monitor, the surgeon repairs the hernia using synthetic mesh
or “screen.”
People who undergo laparoscopic hernia repair generally experience a shorter recovery time than those
who have an open hernia repair.Surgery to repair an inguinal hernia is quite safe, and complications
are uncommon. However, the health care provider should assess for any of the following symptoms
• redness around or drainage from the incision
• fever
• bleeding from the incision
• pain that is not relieved by medication or pain that suddenly worsens
Page 534
Text D
Nursing Interventions
• Place the patient in the Trendelenburg’s position to reduce pressure on the hernia site.
• Apply truss only after the hernia has been reduced. For best results, apply it in the morning
before the patient gets out of bed.
• Assess the skin daily and apply powder to prevent irritation.
• Watch for and immediately report signs of incarceration and strangulation.
• Closely monitor vital signs and provide routine preoperative preparation.
• Administer IV fluids and analgesics for pain as ordered.
• Control fever with acetaminophen.
• A person with an inguinal hernia may be able to prevent symptoms by eating high-fiber foods.This
may help prevent the constipation and straining that cause some of the painful symptoms of a
hernia.
Postoperative interventions:
• Provide routine postoperative care.
• Do not allow the patient to cough.
• Encourage deep breathing and frequent turning.
• Apply ice bags to the scrotum to reduce swelling and relieve pain; elevating the scrotum on
rolled towels may also help to alleviate swelling.
• Administer analgesic as prescribed.
• In males, a jock strap or suspensory bandage may be used to provide support.
END OF PART A
Page 535
Part A
Time: 15 minutes
Inguinal Hernia : Questions
Questions 1-6

1. Rationale for inguinal hernia ________________________________
2. What happens during surgery ________________________________
3. Care before and after surgery ________________________________
4. Potential complications post operatively ________________________________
5. Forms of inguinal hernia ________________________________
6. Recovering from inguinal hernia repair ________________________________
Questions 7-14
7. Which is the site of incision for open hernia repair?
________________________________________________________________
8. What medication is used to control fever caused by hernia?

________________________________________________________________
9. Which group is at the risk of developing direct inguinal hernia?

________________________________________________________________
10. Which device is used to view the internal body in laparoscopic surgery?
________________________________________________________________
11. What is the type of hernia repair surgery where a mesh patch is sewn over the weakened region?
________________________________________________________________
12. Which surgery needs less recovery time?

________________________________________________________________
Page 536
13. Who is more prone to develop inguinal hernias?
________________________________________________________________
14. Which position is recommended to relieve crushing on the point of hernia?

________________________________________________________________
Questions 15-20
15. The food that is rich in _____________________________ aids in hindering symptoms.
16. Inorder to numb the lower part of the body a drug is injected in the spine over the _______________________
17. The deformityin indirect inguinal hernia is not _____________________________ as it is in the back of fibers of
the external oblique muscle.
18. The _____________________________ associated with inguinal hernia is typically exacerbated by common
activities.
19. Open surgery usually requires one large incision instead of several small incisions as in
_____________________________ surgery for hernia repair.
20. In direct inguinal hernia defect in the abdominal wall is felt on top of the _____________________________
END OF PART A
Page 537
Part B
1. Priority during physical examination must be given to
A informed consent of the patient

B appropriate length of the test
C full comfort experienced by them
Sexual boundaries in the doctor-patient relationship

Best practice during consultation Physical examination
You should only conduct a physical examination if it is clinically warranted. You must obtain the patient’s
consent before conducting a physical examination. You must also obtain the patient’s consent prior to
the start of the consultation if an observer or chaperone attends the consultation.
Make sure the patient is aware that they should voice any feelings of discomfort or pain and that they
can ask you to stop the examination at any time.
If the consultation involves a physical examination that requires the patient to remove their clothes, you
should provide an appropriate place to undress. This is an area where the patient can undress in private,
out of view of anyone else, including you.
You should not require a patient to undress unnecessarily or stay undressed for unnecessary lengths of
time. For example, the patient only needs to uncover the part of the body that is being examined, and
should be allowed to cover it again as soon as you have finished. When another person is present during
a consultation.
You or your patient may want another person present during a consultation.
Page 538
2. The advice below can best be applied to a healthcare setting by
A the inclusion of nurses in governance structures

B providing relevant information to patients in their native language
C redesigning projects according to advisory group recommendations
Working with patients and consumers
Partnerships with consumers can come in many forms. Some examples include:
• working with consumers to check that the health information is easy to understand
• using communication strategies and decision support tools that tailor messages to the consumer
• including consumers in governance structures to ensure organisational policies and processes meet
the needs of consumers
• involving consumers in critical friends groups to provide advice on safety and quality projects
• establishing consumer advisory groups to inform design or redesign projects.
Page 539
3. The notice is giving information about
A differential management of infants using glucose

B How to check an infant’s blood glucose level
C The ideal glucose concentration in infants with clinical signs
Management of documented hypoglycemia in breastfeeding

infants
A. Infants with no clinical signs
1. Continue breastfeeding (approximately every 1 to 2 hours) or feed 3 to 10 mL/kg of expressed breast

milk or substitute nutrition.
2. Recheck blood glucose concentration before subsequent feedings until the value is acceptable and
stable.
3. Avoid forced feedings.
4. If glucose remains low despite feedings, begin intravenous glucose therapy.
5. Breastfeeding may continue during IV glucose therapy.
6. Carefully document response to treatment.
B. Infants with clinical signs or plasma glucose levels 20 to 25 mg/dL (1.1 to 1.4 mmol/L)
1. Initiate intravenous 10% glucose solution.
2. Do not rely on oral or intragastric feeding to correct extreme or symptomatic hypoglycemia.
3. The glucose concentration in symptomatic infants should be maintained 45 mg/dL (2.5 mmol/L).
4. Adjust intravenous rate by blood glucose concentration.
5. Encourage frequent breastfeeding.
6. Monitor glucose concentrations before feedings as the IV is weaned until values stabilize off intrave-
nous fluids.
7. Carefully document response to treatmenti
Page 540
4. The information sheet recommends
A regular auditing to ensure pain management program efficacy

B indicators to use in pain management program audits
C at least 50% change as being clinically important
Audit of pain management programs: Methods
It is recommended to conduct an audit of 20 or more sequential patients undertaking a pain manage-

ment program. Data collection should include simple demographic and program data as well as data
(pre and post program with a minimum three month interval between data sets) regarding changes in:
• Healthcare utilisation.
• Depression/anxiety/stress.
• Pain self efficacy.
• Pain catastrophising.
Percentage change in individual patients has been suggested (rather than average percentage change
across the population audited) as average percentage change is very sensitive to outliers and small
audits may therefore be significantly influenced by average percentage change.
The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recom-
mends considering clinical important change (as distinct from statistically significant change) on the
following basis:
• Minimal benefit 10-20 per cent change.

• Moderately important benefit at least 30 per cent change.
• Substantially important benefit at least 50 per cent change.
Page 541
5. The purpose of the guideline is to
A prevent medicare claims being paid for public patients

B specify when services can be billed to Medicare
C ensure healthcare professionals don’t falsify claims
Guideline for substantiating claims for diagnostic imaging and

pathology services rendered to emergency department patients
of public hospitals
Public hospitals are funded under an arrangement with the Australian Government to provide free public
hospital services to eligible patients. This includes diagnostic imaging and pathology services provided
to public hospital emergency department patients. A patient who presents to a public hospital emer-
gency department should be treated as a public patient. If that patient is subsequently admitted they
may elect to be treated as a private patient for those admitted services. For a Medicare claim to be paid
for a patient in a public hospital, the patient must be admitted as a private patient at the time the service
was rendered. Where a service for a patient in a public hospital has been billed to Medicare, the hospital
or rendering practitioner may be asked to substantiate these claims.
Documents you may use include:
• the form which the patient (or next of kin, carer or guardian) - has signed indicating that the
patient has elected to be admitted as a private patient, and
• patient records - that show the patient was admitted as a private patient at the time the service was
rendered
Page 542
6. Healthy ageing according to the information guide is
A functional ability that enables well being

B holistic health which is shaped by environment
C wholesome potential of an individual to exist
What is Healthy Ageing?
Every person – in every country in the world – should have the opportunity to live a long and healthy life.
Yet, the environments in which we live can favour health or be harmful to it. Environments are highly
influential on our behaviour, our exposure to health risks (for example air pollution, violence), our access
to quality health and social care and the opportunities that ageing brings. Healthy Ageing is about
creating the environments and opportunities that enable people to be and do what they value throughout
their lives. Everybody can experience Healthy Ageing. Being free of disease or infirmity is not a require-
ment for Healthy Ageing as many older adults have one or more health conditions that, when well
controlled, have little influence on their wellbeing. WHO defines Healthy Ageing “as the process of
developing and maintaining the functional ability that enables wellbeing in older age”. Functional ability
is about having the capabilities that enable all people to be and do what they have reason to value.
Page 543
Part C
In this part of the test, there will be a text about different aspects of healthcare. For questions 7-22, choose the
answer (A, B, C or D) which you think fits best according to the text.
Text 1: Seasonal Influenza Vaccination and the H1N1 Virus
As the novel pandemic influenza A (H1N1) virus spread around the world in late spring 2009 with a well-
matched pandemic vaccine not immediately available, the question of partial protection afforded by seasonal
influenza vaccine arose. Coverage of the seasonal influenza vaccine had reached 30%– 40% in the general
population in 2008–09 in the US and Canada, following recent expansion of vaccine recommendations.
The spring 2009 pandemic wave was the perfect opportunity to address the association between seasonal
trivalent inactivated influenza vaccine (TIV) and risk of pandemic illness. In an issue of PLoS Medicine,
Danuta Skowronski and colleagues report the unexpected results of a series of Canadian epidemiological
studies suggesting a counterproductive effect of the vaccine. The findings are based on Canada's unique near-
real-time sentinel system for monitoring influenza vaccine effectiveness. Patients with influenza-like illness
who presented to a network of participating physicians were tested for influenza virus by RT-PCR, and information
on demographics, clinical outcomes, and vaccine status was collected. In this sentinel system, vaccine
effectiveness may be measured by comparing vaccination status among influenza-positive “case” patients
with influenza- negative “control” patients. This approach has produced accurate measures of vaccine
effectiveness for TIV in the past, with estimates of protection in healthy adults higher when the vaccine is well-
matched with circulating influenza strains and lower for mismatched seasons. The sentinel system was
expanded to continue during April to July 2009, as the H1N1 virus defied influenza seasonality and rapidly
became dominant over seasonal influenza viruses in Canada.
The Canadian sentinel study showed that receipt of TIV in the previous season (autumn 2008) appeared to
increase the risk of H1N1 illness by 1.03- to 2.74-fold, even after adjustment for the comorbidities of age and
geography. The investigators were prudent and conducted multiple sensitivity analyses to attempt to explain
their perplexing findings. Importantly, TIV remained protective against seasonal influenza viruses circulating in
April through May 2009, with an effectiveness estimated at 56%, suggesting that the system had not suddenly
become flawed. TIV appeared as a risk factor in people under 50, but not in seniors—although senior estimates
were imprecise due to lower rates of pandemic illness in that age group. Interestingly, if vaccine were truly a
risk factor in younger adults, seniors may have fared better because their immune response to vaccination is
less rigorous.
The Canadian authors provided a full description of their study population and carefully compared vaccine
coverage and prevalence of comorbidities in controls with national or province-level age-specific estimates—
the best one can do short of a randomized study. In parallel, profound bias in observational studies of vaccine
effectiveness does exist, as was amply documented in several cohort studies overestimating the mortality
benefits of seasonal influenza vaccination in seniors.
Page 544
Given the uncertainty associated with observational studies, we believe it would be premature to conclude
that TIV increased the risk of 2009 pandemic illness, especially in light of six other contemporaneous
observational studies in civilian populations that have produced highly conflicting results. We note the large
spread of vaccine effectiveness estimates in those studies; indeed, four of the studies set in the US and
Australia did not show any association whereas two Mexican studies suggested a protective effect of 35%–
73%.
The alleged association between seasonal vaccination and 2009 H1N1 illness remains an open question,
given the conflicting evidence from available research. Canadian health authorities debated whether to postpone
seasonal vaccination in the autumn of 2009 until after a second pandemic wave had occurred, but decided to
follow normal vaccine recommendations instead because of concern about a resurgence of seasonal influenza
viruses during the 2009–10 season. This illustrates the difficulty of making policy decisions in the midst of a
public health crisis, when officials must rely on limited and possibly biased evidence from observational data,
even in the best possible scenario of a well-established sentinel monitoring system already in place.
What happens next? Given the timeliness of the Canadian sentinel system, data on the association between
seasonal TIV and risk of H1N1 illness during the autumn 2009 pandemic wave will become available very
soon, and will be crucial in confirming or refuting the earlier Canadian results. In addition, evidence may be
gained from disease patterns during the autumn 2009 pandemic wave in other countries and from immunological
studies characterizing the baseline immunological status of vaccinated and unvaccinated populations. Overall,
this perplexing experience in Canada teaches us how to best react to disparate and conflicting studies and
can aid in preparing for the next public health crisis.
Page 545
7. The question of partial protection against H1N1 arose
A before spring 2009

B during Spring 2009
C after spring 2009
D during 2008-09
8. According to Danuta Skowronski
A the inactivated influenza vaccine may not be having the desired effects.
B Canada’s near-real-time sentinel system is unique.
C the epidemiological studies were counterproductive
D the inactivated influenza vaccine has proven to be ineffective.
9. The vaccine achieved higher rates of protection in healthy adults when
A it was supported by physicians.

B the sentinel system was expanded.
C used in the right season.
D it was matched with other current strains.
10. Which one of the following is closest in meaning to the word prudent in paragraph 3?
A anxious
B cautious
C busy
D confused
11. The Canadian sentinel study demonstrated that…..
A age and geography had no effect on the vaccine’s effectiveness.

B vaccinations on senior citizens is less effective than on younger people.
C the vaccination was no longer effective.
D the risk of H1N1 seemed higher among people who received the TIV vaccination.
Page 546
12. Which of the following sentences best summarises the writers’ opinion regarding the uncertainty
associated with observational studies?
A More studies are needed to determine whether TIV increased the risk of the 2009 pandemic.
B It is early to tell whether the risk of catching the 2009 pandemic illness increased due to TIV.
C Studies show that there is no association between TIV and increased risk of 2009 pandemic.
D Civilian populations are less at risk of catching the 2009 pandemic illness.
13. Which one of the following is closest in meaning to the word alleged in paragraph 6?
A reported
B likely
C suspected
D possible
14. Canadian health authorities did not postpone the Autumn 2009 seasonal vaccination because…
A of a fear seasonal influenza viruses would reappear in the 2009-10 season.

B there was too much conflicting evidence regarding the effectiveness of the vaccine.
C the sentinel monitoring system was well established.
D observational data may have been biased.
Page 547
Text 2: Addiction to prescription
Addiction to prescription pain killers is soaring, with the number of Victorians being treated in hospital emergency
departments more than doubling in the past five years. Health experts say the crisis is partly driven by
suburban white-collar patients who get hooked after being prescribed opiate-based pills such as morphine
and oxycodone for chronic pain.
With an ageing population fuelling a jump in conditions such as arthritis, they fear addiction to pain killers will
rise further. Since 1991, there has been a 40-fold rise in morphine tablet use in Australia, while use of
oxycodone has quadrupled.
Medical professionals are now so concerned about pain killers abuse that 70 leading GPs, physiotherapists,
chiropractors, and pain-management specialists convened a national pain summit in Melbourne last week.
The experts backed by the college of anaesthetists, the college of General Practitioners and the college of
Physicians, will present Prime Minister Kevin Rudd with a plan to tackle the crisis before the end of the year.
The clinical director of alcohol and drug services at Southern and Eastern Health, Dr Matthew Frein, will tell
the annexe Australian drugs conference in Melbourne this week that the number of pain killer addicts going to
the Monash Medical Centre and Dandenong Hospital Emergency Departments jumped from about 150 in
2005 to 300 so far this year. In the same period, there has been a corresponding drop in hospital visits heroin
abuse.
This shift, which Dr. Frein believes is mirrored at hospitals across Victoria, is partly due to former heroin users
switching to cheaper prescription drugs and has been compounded by a short age of heroin and underfunding
of methadone programmes.
The problem was also being fuelled by people being prescribed pain medication after orthopaedic surgery or
major injuries. When the drugs failed to work, the dosage was increased. “That can often become a battle
against pain that the doctor and patient can never win,” he said. “The jury’s not out on whether this is a major
problem for drug treatment services – the jury’s back in. This is becoming the bread and butter of what we
do”. Dr. Frein said he believed Australia could go the same way as the United States where abuse of
prescription pain killers is soaring. Richard Smith from addiction, the Raymond Hader Clinic, said Australians
were already the highest per capita users of analgesics (paracetamol and aspirin) in the world. He said pill-
popping had been “normalised” by Hollywood’s widespread use of prescription medication. Singer Michael
Jackson was believed to be addicted to pain killers at the time of his death, and actor Heath Ledger died from
an accidental overdose of prescription drugs including oxycontin. Dr. Smith said: “we recently saw a woman
with two young kids. She had a back injury and was advised to have operations, putting in braces... She
ended up with serious pain from the operations and was getting some serious medication. The withdrawal
symptoms are the same as heroin if not worse”. Dr. Frein said addicted patients often “Doctor-shopped” to
get a new prescription or told their GP they had lost the first one. When refused, they often went to an
emergency department.
Morphine and oxycodone are scheduled 8 substances, requiring a permit before being prescribed. Strict
criteria should be met before a prescription is offered to minimise the risk of dependency, but there are
concerns that busy GPs are overprescribing instead of offering alternatives such as psychological therapy
and relaxation techniques. Dr Penelope Briscoe of the Australian and New Zealand college of anaesthetists
said medication reduced pain by only about 30% and failed to work for 2 out of 3 patients.
John Ryan, chief of harm-reduction group annexe warned: “One of the complications of pharmaceutical use is
half life. It means people can take a drug and think they’ve cleared it from their system because they don’t feel
any effects but its still there and it puts them at risk of overdose”.
Page 548
15. The author states that
A People treated in hospital EDs has risen dramatically in the past five years
B The number of EDs in Victoria have more than doubled in the past five years
C The number of prescription painkillers has doubled in the past five years.
D Victorians requiring hospitalisation for addiction has risen by more than 100% in the past
five years
16. According to this journalist
A Medical experts will be reporting to an Australian Drugs Conference later in October, 2009
B Health (including pain) specialists arranged an Australia-wide seminar in Melbourne
C Medical experts and others will present a plan to solve the crisis by the end of 2009.
D A Clinical Director asserts that the number of addicts has doubled during the past year.
17. The idea expressed by Bread and butter in paragraph five is
A doctors pay too much attention to pain

B judgement on the procedure is reserved
C such means of treatment are unrestrained
D consequences of administration are numerous
18. What does Doctor-shopped in the fifth paragraph refer to
A visiting many doctors for prescriptions

B bargaining with medics for relievers
C using the same prescription over again
D choosing the professional on pills given
Page 549
19. According to Richard Smith:
A Australians are the biggest users of analgesics in the world

B Australians were following in the footsteps of Hollywood celebrities
C People with back injuries get relief from strong pain killers
D Paracetamol and aspirin were popular forms of painkillers in the U.S.
20. The article refers to addicted patients
A who should be asking for other alternatives rather than a prescription for painkillers
B using a variety of strategies to get prescriptions filled.
C going from one doctor to another to get a prescription filled.
D pressuring overworked GP’s to write out another prescription.
21. Reported statistics shows that
A 30% of patients received pain relief from painkillers

B In two thirds of patients, painkillers had better effect than nothing at all.
C Patients using painkillers reported a 30% reduction in pain
D Painkillers were successful in 66% of patients.
22. The paragraph that starts with “This shift, which Dr Frei believes’ which refers to
A Painkiller addicts now attend Dandenong Hospital rather than Monash Medical
B The overall increase in addict numbers with previous figures
C As painkiller addict numbers have risen, there’s been a decrease in heroin abusers
D As painkiller addict numbers have risen, there’s been a decrease in heroin users
END OF READING TEST

Page 550
READING SUB-TEST 5
1 A
2 C
3 D
4 C
5 B
6 D
7 the groin
8 acetaminophen
9 old age
10 laproscope
11 open hernia repair
12 laproscopic
13 men
14 Trendelenberg’s
15 fibre
16 nerves
17 palpable
18 symptoms
19 laproscopy
20 pubic tubercle
Page 551
1 A informed consent of the patient

2 B providing relevant information to patients in their native language
3 A differential management of infants using glucose
4 B indicators to use in pain management program audits
5 A prevent medicare claims being paid for public patients
6 A functional ability that enables well being
7 B during Spring 2009

8 A the inactivated influenza vaccine may not be having the desired effects
9 D it was matched with other current strains.
10 B cautious
11 D the risk of H1N1 seemed higher among people who received the TIV vaccination
12 B It is early to tell whether the risk of catching the 2009 pandemic illness increased
due to TIV.
13 C suspected
14 A of a fear seasonal influenza viruses would reappear in the 2009-10 season.
15 D Victorians requiring hospitalisation for addiction has risen by more than 100% in
the past five years
16 B Health (including pain) specialists arranged an Australia-wide seminar in Melbourne
17 C such means of treatment are unrestrained
18 D choosing the professional on pills given
19 A Australians are the biggest users of analgesics in the world
20 C going from one doctor to another to get a prescription filled.
21 C Patients using painkillers reported a 30% reduction in pain
22 C As painkiller addict numbers have risen, there’s been a decrease in heroin abusers
Page 552
26
Sample Test 3
Page 553
Management of burns: Texts
Text A
Burn depth
Burn injuries are classified according to how much tissue damage is present.
1 Superficial partial thickness burns (also known as first and second degree)
Present in most burn wounds. Injuries do not extend through all the layers of skin.
2 Full thickness burns (also known as third degree)

• Burn extends into the subcutaneous tissues
•
E
Underlying tissue may appear pale or blackened
• Remaining skin may be dry and white, brown or black with no blisters
L
• Healing associated with considerable contraction and scarring.
3 Mixed depth burns
P
Burns are frequently of mixed depth. The clinician should estimate the average depth by the appearance
and the presence of sensation.
Resuscitation should be based on the total of second and third degree burns, and local treatment should
M
be based on the burn thickness at any specific site.
A
Text B
S
Fluid resuscitation
If the burn area is over 15% of the TBSA (Total Body Surface Area) in adults or 10% in children, intravenous
fluids should be started as soon as possible on scene, although transfer should not be delayed by more
than two cannulation attempts. For physiological reasons the threshold is closer to 10% in the elderly (>60
years).
Suggested regimen for fluid resuscitation
Adults
Resuscitation fluid alone (first 24 hours)
• Give 3–4ml Hartmann's solution (3ml in superficial and partial thickness burns/4ml in full
thickness burns or those with associated inhalation injury) per kg body weight/% TBSA burned. Half
of this volume is given in the first 8 hours after injury and the remaining half in the second 16-hour
period
Children
Resuscitation fluid as above plus maintenance (0.45% saline with 5% dextrose):
• Give 100ml/kg for the first 10kg body weight plus 50ml/kg for the next 10kg body weight plus

20ml/kg for each extra kg

SAMPLE

Text C
Management for Burns

1. Assess the patient status: airway, breathing, circulation, IV access.

2. Assess the burn depth and extent. A sheet can be placed on burns during this time.

3. Cooling: Remove jewellery or hot clothing. Limit inflammation and pain by using cool water, cool
saline soaked gauze or a large sheet in the case of a large wound. Cool the wound not the patient,
taking care not to cause hypothermia.
4. Pain Control: Acetaminophen usually helpful but may need to use opiates such as codeine.

5. Check immunization status and update tetanus if necessary.

6. If possible, begin fluid resuscitation.
E
7. Debridement of blisters – there are some differences of opinion regarding breaking of blisters.

a. Some suggest leaving intact because the blister acts as a barrier to infection and others
L

debride all blisters.
b. Most agree that necrotic skin should be removed following blister ruptures.

8. Application of antibiotics in the form of ointment. Should always be used to prevent infection in any
P

non-superficial burns.
9. Apply suitable dressing to the wound area.

M
Text D
A
Adult Analgesic Guidelines
The following table provides recommended short term (<72 hours) oral analgesia guidelines for the
S
management of burn injuries. Aim for pain scores of 4 or less at rest. Analgesia should be reviewed after
72 hours and adjusted according to pain scores. Patient management should be guided by individual
case and clinical judgement.
Pain score elicited from patient (Scale 1 – 10)

Mild Pain Moderate Pain Severe Pain
Pain Score 1 - 3 Pain Score 4 - 6 Pain Score 7 - 10
Recommended analgesia: Recommended analgesia in Recommended analgesia in
addition to column 1: addition to column 1 & 2:
Paracetamol 1g 4 x daily Tramadol 50 – 100mg 4 x daily Strong opioids
Oxycontin SR 10mg (2 x daily)
And if needed: If above unsuccessful:
Naproxen 250mg 2 x daily Endone (immediate release Endone, 2 - 4 hourly as needed
oxycodone) 5 – 10mg (2 - 4
hourly)
Review in 72 hours Review in 72 hours
If pain cannot be controlled
with oral medications, consider
admission to burns unit.
Paediatric Analgesia Guidelines

• Paracetamol (15 mg/kg (max 90 mg/kg/day) orally or per rectum (PR))
• Non Steroidal Anti-Inflammatory Drugs
• naproxen 5 - 10 mg/kg (max 500 mg) 12-hrly orally or PR
• ibuprofen 2.5 - 10 mg/kg (max 600 mg) 6-8hrly orally
• Opioids (codeine 0.5 - 1 mg/kg orally)
END OF PART A SAMPLE


Part A
TIME: 15 minutes
• Look at the four texts A-D, in the separate Text Booklet.
• For each question 1-20, look through the texts, A-D, to find the relevant information.
• Write your answers in the spaces provided in this Question Paper.
• Your answers should only be taken from texts A-D and must be correctly spelt.
Management of burns: Questions
E
Questions 1-5
L
P
1 age-related considerations for initial treatment of burns injuries?

M
2 the risks involved in certain treatments?

3 when to start thinking about specialist treatment options?
A

4 treatment informed by patient self-assessment?

S
5 how to categorise the severity of a burn?

Questions 6-13
Complete each of the sentences, 6-13, with a word or short phrase from one of the texts. Each answer may include
6 Classification of burn injuries depends on the amount of
caused.
7 Patients recovering from third degree burns are likely to experience a great deal of shrinkage and
of their skin.
8 When evaluating mixed depth burns, you should take into account how the burn looks and whether

there is in the affected area.
9 You should cool burn injuries by taking off any or jewellery that

the patient is wearing.
SAMPLE

10 When cooling the wound, make sure that you don’t put the patient at risk

of .
11 The patient may require a booster, depending on when they

were last immunised.
12 You should consider leaving undisturbed, as these may help

prevent infection.
E
13 You should apply ointments containing to all deeper burns.

L
Questions 14-20
P
Answer each of the questions, 14-20, with a word or short phrase from one of the texts. Each answer may include
M
14 In the case of mixed depth burns, what factor determines the local treatment to give?

A
15 What is the maximum number of tries recommended for attaching a drip at the scene of a burns

S
incident?
16 How much resuscitation fluid should a child receive per kilo over 20kg?
17 Before attaching a fluid resuscitation drip to a 9-year-old burns patient, what percentage of the body
needs to be affected?
18 What additional analgesic is recommended in the first instance for a patient with a moderate level of
pain?
19 What route should be used to administer ibuprofen to children?

20 After how long should a patient’s pain relief regime be re-evaluated?

END OF PART A
SAMPLE


Part B
choose the answer (A, B or C) which you think fits best according to the text. A

B
Fill the circle in completely. Example: C
1. Doctors are advised to break patient confidentiality if
A failure to do so would put other people in danger.
E
B they inform the patient of their intention in advance.
C a patient refuses to disclose information relevant to their care.
Patient Confidentiality
P L
M
Confidentiality is central to trust between doctors and patients. Without assurances about confidentiality,
patients may be reluctant to seek medical attention or to give doctors the information they need in order
A
to provide good care.
However, faced with a situation in which a patient’s refusal to consent to disclosure leaves others
S
exposed to a risk so serious that it outweighs the patient’s and the public interest in maintaining
confidentiality, or if it is not practical or safe to seek the patient’s consent, information should be
disclosed promptly to an appropriate person or authority. The patient should be informed in advance that
the doctor will be disclosing the information, provided this is practical and safe, even if the doctor intends
to disclose without the patient’s consent.
SAMPLE
2. According to the guidance notes, all staff involved in transferring patients from critical to general care must
A obtain all necessary consent from any interested parties.
B ensure that the patient’s personal care plan is also transferred.
C make arrangements for ongoing co-operation once the transfer is complete.
E
Transfer of patients
1.15
L
The critical care area transferring team and the receiving ward team should take shared responsibility for
the care of the patient being transferred. They should jointly ensure that:
P
• there is continuity of care through a formal structured handover from critical care area staff to ward
. staff (including both medical and nursing staff), supported by a written plan;
M
• the receiving ward, with support from critical care if required, can deliver the agreed plan.
1.16
A
When patients are transferred to the general ward from a critical care area, they should be offered
information about their condition and encouraged to actively participate in decisions that relate to their
S
recovery. The information should be tailored to individual circumstances. If they agree, their family and
carers should be involved.
SAMPLE
3. The memo says failure to screen a patient for malnutrition may result in
A a change in overall health.
B a prolonged stay at the care facility.
C care providers being unaware of an issue.
E
Memo
To: Hospital staff
L
Re: Nutrition screening
P
This is to remind staff of the importance of nutrition screening to identify problems which may go unrecognised
and, therefore, remain untreated during the patient’s hospital stay. Nutrition screening should occur on
M
admission and then weekly during the patient’s episode of care; at least monthly in slower stream facilities; or if
the patient’s clinical condition changes.
A
All patients should have their weight and height documented on admission, and weight should continue to
be recorded at least weekly. Patients whose score is ‘at risk’ on a validated screening tool or whose clinical
S
condition is such that their treating team identifies them as at risk of malnutrition should be referred to a
dietitian for a full nutrition assessment and nutrition support as appropriate.
SAMPLE
4. This policy document states that nurses
A must sign a paper form if they want any new stock.
B can order medicines from the pharmacy in some cases.
C should speak to the pharmacist if a drug is needed urgently.
E
Stock requisitioning
If stock levels of a medicine are low, the nurse should firstly liaise directly with their ward-based team to
L
arrange urgent stock replenishment. If the ward-based team is unavailable, the nurse should complete
a request form online and email it to the pharmacy stores. Paper-based ordering systems are available
P
(e.g. the ward medicines requisition book); however these should not be relied on if ward stock is urgently
needed.
M
“At risk medicines” – Diazepam/Codeine Phosphate/Co-codamol – may only be ordered for stock when
a paper requisition is written. Paper-based requisitions should be complete, legible and signed, and then
A
sent to the pharmacy department.
Wards/clinical areas using Mediwell 365 cabinets will have orders transmitted automatically to Pharmacy
S
on a daily basis, as stock is used.
SAMPLE
5. The extract from the guidelines states that
A ICU staff can be seconded to other wards.
B only a consultant can refer a patient to the ICU.
C the ICU is fully responsible for a patient in their care.
E
6.2 Intensive Care Unit (ICU)
L
6.2.1 Unplanned admissions to the ICU need a referral at consultant level. In exceptional circumstances,
referrals will be discussed with the Ward Registrar looking after the patient if a delay in referral to ICU
P
would lead to the rapid deterioration of a patient.
6.2.2 All patients discussed with the ICU staff but not admitted remain under the care of the primary team
and as such they remain responsible for reviewing and escalating care should deterioration occur.
M
6.2.3 We encourage collaborative patient-centred care. However the ICU is defined as a closed unit.
A
This means that when patients are admitted into the ICU, they are under the care of the ICU team. It is
expected that members of the primary referring team will liaise daily with the ICU team to discuss the
patient’s management. However, it is up to the ICU team to make final decisions.
SAMPLE
6. When dealing with patients following a safety incident, staff must avoid
A saying anything until the facts have been established.
B speculating on the possible causes of the incident.
C contradicting what has been said by other staff.
Patient Safety Incidents
E
Information about a patient safety incident must be given to patients and/or their carers in a truthful
L
and open manner by an appropriately nominated person. Patients want a step-by-step explanation of
what happened that considers their individual needs and is delivered openly. Communication must also
P
be timely – patients and/or carers should be provided with information about what happened as soon
as practicable. It is also essential that any information given is based solely on the facts known at the
M
time. Healthcare staff should explain that new information may emerge as an incident investigation is
undertaken, and patients and/or their carers will be kept up-to-date with the progress of an investigation.
A
The Duty of Candour Regulations require that information be given as soon as is reasonably practicable
and be given in writing no later than 10 days after the incident was reported through the local systems.
SAMPLE
Part C
A
answer (A, B, C or D) which you think fits best according to the text. B
C
Fill the circle in completely. Example: D
Text 1: Allergic to eating
Lucy Smith was strolling through Canberra last July. Within moments she couldn't stand, gripped by pain so severe
she feared she would pass out – the first sign of paralysing diarrhoea. This dramatic episode turned out to be
E
caused by a newly-acquired food allergy – to red meat. Food allergies affect one per cent of the adult population of
Australia. Most don’t hit with the same force as Lucy's, but the physical and mental impact can nonetheless turn a
L
person's life upside down, and may even be life-threatening. Lucy deduced that she was allergic to red meat, one
of the less common allergenic foodstuffs. Only after several further attacks of varying severity, was her suspicion
P
eventually confirmed by a specialist.
An allergy, according to immunologists, is the immune system over-reacting to a substance that would ordinarily
M
be considered benign. However the term 'allergy' is used more loosely by the general public. People say they
are allergic to a substance because it brings about some kind of adverse reaction in their bodies, some of which
A
can be severe and may resemble true allergic reactions, but unless the immune system itself is directly involved,
experts categorise it as 'intolerance'. Constant sneezing, itchy eyes or throat and inner ears, asthma, rashes, and
S
diarrhoea can all be signs of food allergies. Intolerance can bring on similar warning signs as well as things such as
headaches, bloating, and general lethargy. Over time, some allergy sufferers lose weight because there are so few
foods they can eat. Of course the social implications are huge too – eating is a major social event.
To diagnose a food allergy, immunologists use a 'skin-prick test' in which a drop of a commercially extracted
allergen is placed on the skin and the first couple of skin layers are pricked with a lancet. If a person is allergic,
the immune system is stimulated sufficiently to produce a mosquito bite-like bump within fifteen minutes. This
testing method is, however, somewhat unreliable in detecting intolerances, because, while not fully understood,
they operate via a different biological mechanism possibly involving chemicals in food irritating nerve endings
in the body. They are generally diagnosed by following an exclusion diet in which suspect foods are gradually
reintroduced and their effects monitored.
SAMPLE
According to paediatric immunology specialist Dr Velencia Soutter, around six to eight per cent of babies are
affected by allergy. While most children will outgrow them, some actually grow into them. The mechanisms that
provoke an allergy remain a grey area. Soutter says: 'It’s like throwing a match into a fireworks factory. Hit the right
place and you set off a chain reaction. Miss it and the match just fizzles out. That difference between lighting up or
fizzling out isn’t well understood.'
Broadly speaking, Dr Soutter says the ideal recipe for a food allergy is to be born of allergic parents and then
to have a high exposure to an allergenic foodstuff. But there are so many exceptions to this rule that other
forces are clearly at work, and who’s to say what 'high' exposure is anyway? In contrast, the so-called hygiene
E
hypothesis suggests too low an exposure to allergens is to blame. The idea is that today's clean environments
L
leave our immune systems with too little to do, encouraging them to turn on the wrong culprits. Clearly, the field of
immunology has only just scratched the surface of understanding.
P
Interesting flakes of information are gradually being peeled off that surface, however. There is evidence that
allergens can be transferred through a mother's breast milk to her child, and possibly also through the placenta.
M
Since the immaturity of babies' immune systems might make them more vulnerable to an inherited allergic
tendency, women in allergic families could be advised to avoid certain foods during pregnancy and breastfeeding. It
A
is possible, though, that some allergies or intolerances are purely imaginary and this can also have consequences
for children. One US study found that parents sometimes avoided foods to which they erroneously believed their
S
children were allergic, occasionally leaving the children severely underfed.
In Australia, the number of people with genuine and severe allergies is growing. Some doctors speculate whether
the increased amount of new chemicals in the environment and in food is perhaps damaging immune systems
− making them more prone to react adversely. Much more research needs to be done to provide evidence for
that hypothesis. Anecdotally though, some experts say that staying off processed foods resolves the problem in
a significant number of cases. Dr Soutter speculates that a rise in peanut allergy cases makes up the bulk of the
increase in food allergies. Greater exposure has probably allowed more peanut allergies to flourish, she thinks.
Peanut consumption per capita is rising. It's a common ingredient in Asian and vegetarian dishes, which have
grown in popularity, and the diet-conscious population is increasingly turning to nuts as a source of healthy fats.
SAMPLE
7. The case of Lucy Smith highlights the fact that food allergies
A may be difficult to diagnose in certain people.
B are relatively rare in the adult population.
C can cause debilitating symptoms.
D often require urgent treatment.
E
8. In the second paragraph, what point is made about food intolerances?
L
A Scientists continue to disagree about their root causes.
P
B The symptoms are indistinguishable from those of allergies.
C They can have an unpredictable impact on the person affected.
M
D The distinction between them and allergies is not widely appreciated.
A
9. The phrase ‘via a different biological mechanism’ in the third paragraph explains
S
A the way the skin-prick test works in diagnosing food intolerances.
B how the presence of food impurities impacts on the skin-prick test.
C why the skin-prick test may not accurately diagnose food intolerance.
D how food allergies are triggered by substances used in the skin-prick test.
10. Dr Soutter uses the image of a fireworks factory to illustrate that
A the factors triggering an allergic reaction still remain unclear.
B allergic attacks can occur suddenly any time in a person’s life.
C it’s difficult to foresee which family member an allergy will affect.
D the identification of a food allergy is basically a matter of chance.
SAMPLE
11. In the fifth paragraph, what point is made about the two hypotheses mentioned?
A They both appear to be credible.
B They directly contradict each other.
C They fail to define their terms adequately.
D They should both be studied in more depth.
E
12. What does the phrase ‘this rule’ in the fifth paragraph refer to?
L
A the likelihood of having an inherited allergy to certain foods
P
B the type of diet in which food allergies more commonly occur
C the degree of contact with allergens needed to trigger a reaction
M
D the order of events most commonly found prior to allergic attacks
A
13. What does the sixth paragraph suggest about the transference of allergies between mother and child?
S
A It is only possible with particular individuals.
B It can result in instances of malnourishment.
C It may be avoidable if certain precautions are taken.
D It is most likely to take place before the baby is born.
14. Dr Soutter suggests that the rise in cases of one allergy may be partly due to
A attempts to improve eating habits.
B changes in food manufacturing methods.
C the adoption of new agricultural practices.
D increased levels of harmful substances in the atmosphere.
SAMPLE
Text 2: Prenatal origins of heart disease
Heart disease is the greatest killer in the developed world today, currently accounting for 30% of all deaths in
Australia. A concept which is familiar to us all is that traditional risk factors such as smoking, obesity, and genetic
make-up increase the risk of heart disease. However, it is now becoming apparent that another factor is at play – a
developmental programming that is predetermined before birth, not only by our genes but also by their interaction
with the quality of our prenatal environment.
Pregnancies that are complicated by sub-optimal conditions in the womb, such as happens during pre-eclampsia or
E
placental insufficiency, enforce physiological adaptations in the unborn child and placenta. While these adaptations
are necessary to maintain viable pregnancy and sustain life before birth, they come at a cost. The biological trade-
L
off is reduced growth, which may in turn affect the development of key organs and systems such as the heart and
circulation, thereby increasing the risk of cardiovascular disease in adult life. Overwhelming evidence in more than
P
a dozen countries has linked development under adverse intrauterine conditions leading to low birth weight with
increased rates in adulthood of coronary heart disease and its major risk factors – hypertension, atherosclerosis
M
and diabetes.
The idea that a foetus’s susceptibility to disease in later life could be programmed by the conditions in the womb
A
has been taken up vigorously by the international research community, with considerable efforts concentrating on
nutrient supply across the placenta as a risk factor. But that is just part of the story: how much oxygen is available
S
to the foetus is also a determinant of growth and of the risk of adult disease. Dr Dino Giussani’s research group
at Cambridge University in the UK is asking what effect reduced oxygen has on foetal development by studying
populations at high altitude.
Giussani’s team studied birth weight records from healthy term pregnancies in two Bolivian cities at obstetric
hospitals and clinics selectively attended by women from either high-income or low-income backgrounds. Bolivia
lies at the heart of South America, split by the Andean Cordillera into areas of very high altitude to the west and
areas at sea-level to the east, as the country extends into the Amazon Basin. At 400m and almost 4000m above
sea-level, respectively, the Bolivian cities of Santa Cruz and La Paz are striking examples of this difference.
Pregnancies at high altitude are subjected to a lower partial pressure of oxygen in the atmosphere compared with
those at sea-level. Women living at high altitude in La Paz are more likely to give birth to underweight babies than
women living in Santa Cruz. But is this a result of reduced oxygen in the womb or poorer nutritional status?
SAMPLE
What Giussani found was that the high-altitude babies showed a pronounced reduction in birth weight compared
with low-altitude babies, even in cases of high maternal nutritional status. Babies born to low-income mothers at
sea-level also showed a reduction in birth weight, but the effect of under-nutrition was not as pronounced as the
effect of high altitude on birth weight; clearly, foetal oxygenation was a more important determinant of foetal growth
within these communities. Remarkably, although one might assume that babies born to mothers of low socio-
economic status at high altitude would show the greatest reduction in birth weight, these babies were actually
heavier than babies born to high-income mothers at high altitude. It turns out that the difference lies in ancestry.
The lower socio-economic groups of La Paz are almost entirely made up of Aymara Indians, an ancient ethnic
E
group with a history in the Bolivian highlands spanning a couple of millennia. On the other hand, individuals of
L
higher socio-economic status represent a largely European and North American admixture, relative newcomers
to high altitude. It seems therefore that an ancestry linked to prolonged high-altitude residence confers protection
against reduced atmospheric oxygen.
P
Giussani’s group also discovered that they can replicate the findings observed in Andean pregnancies in hen
M
eggs: fertilised eggs from Bolivian birds native to sea-level show growth restriction when incubated at high altitude,
whereas eggs from birds that are native to high altitude show a smaller growth restriction. Moving fertilised eggs
A
from hens native to high altitude down to sea-level not only restored growth, but the embryos were actually larger
than sea-level embryos incubated at sea-level. The researchers could thereby demonstrate something that only
generations of migration in human populations would reveal. What’s more, when looking for early markers of
S
cardiovascular disease, the researchers discovered that growth restriction at high altitude was indeed linked with
cardiovascular defects – shown by an increase in the thickness of the walls of the chick heart and aorta. This all
suggests the possibility of halting the development of heart disease at its very origin, bringing preventive medicine
back into the womb.
SAMPLE
15. What information can be found in the first paragraph?
A reference to some recent findings relating to heart disease
B indication of the greatest risk factor associated with heart disease
C mention of a misconception about the chief causes of heart disease
D figures showing the country with the highest mortality rate from heart disease
E
16. When the writer uses the word ‘cost’ in the second paragraph she is referring to
L
A overwhelming evidence.
P
B placental insufficiency.
C viable pregnancy.
M
D reduced growth.
A
17. In the third paragraph, what does the author suggest about the work of the international research
S
community on this subject?
A Their focus has been too narrow.
B Some of their studies may be flawed.
C There is nothing original about their research.
D They were overly keen to seize on a particular idea.
18. What was the aim of the study described in the fourth paragraph?
A to compare neonatal records between the UK and Bolivia
B to assess the relative significance of two risk factors for newborns
C to find a link between birth weight and predisposition to heart disease
D to determine the likelihood of high-altitude babies being carried to full term
SAMPLE
19. What assumption was proved wrong by the results of the study?
A Lower-income mothers generally give birth to lower weight babies.
B A baby born at high altitude will typically weigh less than one born at sea level.
C Levels of oxygen have a greater impact on birth weight than nutritional status does.
D There is a correlation between prenatal oxygen levels and predisposition to heart disease.
E
20. In the sixth paragraph, what is suggested about the inhabitants of La Paz?
L
A The altitude affects all socio-economic groups in a similar way.
P
B There is a high degree of ethnic diversity at all levels of society.
C Most residents have a shared ancestry going back two thousand years.
M
D Poorer residents have a genetic advantage over those with higher incomes.
A
21. The purpose of the information in the sixth paragraph is to provide
S
A an alternative approach to a puzzle.
B a confirmation of a hypothesis.
C an explanation for a finding.
D a solution to a problem.
22. What advantage of the research involving hen eggs is mentioned in the final paragraph?
A the availability of supplies
B the simplicity of the procedure
C the reliability of the data obtained
D the speed with which results are seen
END OF READING TEST

SAMPLE
PART A: QUESTIONS 1-20
1 B

2 C

3 D

4 D

5 A

6 tissue damage

7 scarring
E

8 sensation

9 hot clothing
L

10 hypothermia

11 tetanus
P

12 blisters

13 antibiotics

M
14 thickness

15 2 / two
A

16 20ml

17 10% / ten percent
S

18 Tramadol

19 orally

20 72 hours

Page 572 1
READING SUB-TEST - ANSWER KEY
1 failure to do so would put other people in danger.

2 B ensure that the patient’s personal care plan is also transferred.
3 care providers being unaware of an issue.

4 B can order medicines from the pharmacy in some cases.
5 the ICU is fully responsible for a patient in their care.

6 B speculating on the possible causes of the incident.
E
L
7 C can cause debilitating symptoms.
P
8 D The distinction between them and allergies is not widely appreciated.
9 C why the skin-prick test may not accurately diagnose food intolerance.
M
10 A the factors triggering an allergic reaction still remain unclear.
11 They directly contradict each other.

A
12 D the order of events most commonly found prior to allergic attacks
13 C It may be avoidable if certain precautions are taken.
S
14 A attempts to improve eating habits.
15 A reference to some recent findings relating to heart disease
16 D reduced growth.
17 A Their focus has been too narrow.
18 B to assess the relative significance of two risk factors for newborns
19 A Lower-income mothers generally give birth to lower weight babies.
20 D Poorer residents have a genetic advantage over those with higher incomes.
21 an explanation for a finding.

22 D the speed with which results are seen
Page 573 1
THE END
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READING

Medicine, nursing, dietetics, dentistry, occupational therapy, optometry, pharmacy, physiotherapy,

Kaplan Strategies & Practice Set

Which medication a patient receives depends on their age and ethnicity.

The following are indicators of high blood pressure:

Severe, sudden and recurring headaches

Hypotension 70–89 or 40–59

Normal Blood Pressure 90–119 and 60–79

Prehypertension 120–139 or 80–89

Stage 1 (Mild) ​Hypertension 140–159 or 90–99

Stage 2 (Moderate) ​- 160–179 or 100–109

Stage 3 (Severe) ​Hypertension 180–209 or 110–119

3. Look in Text D to find which category of blood pressure a diastolic

4. Look in Text B to find what type of exercise patients should do two

Patients taking an excessive amount of L-thyroxine may experience the

Advise patients to be aware of these symptoms, and to seek immediate medical

Care must be taken to identify and preserve recurrent laryngeal

Superficial laryngeal nerve injury reported in 2% (5 out of 300) of

Mutation testing should be undertaken to avoid unnecessary surgery and reduce

A test for a BRAF V600E mutation can be performed using a commercially

Thyroid Function Test Results and Analysis

Decreased Normal Normal — thyroxine treatment/ingestion

Increased Normal Normal — subclinical hypothyroidism

Normal or Normal or Normal or

Page 11 resistance to thyroid hormone

6. identifying the risk of malignant cancer of the thyroid? __________

Answer questions 12 – 16 using the 4 texts on pages 71 to 74. For each

12. What will the level of FT4 be in patients undergoing thyroxine

14. Which type of thyroidectomy has an increased chance of morbidity?

16. What can be tested for using a commercially available kit?

17. If thyroid function tests indicate that TSH has (17)

18. Following a thyroidectomy, if the patient experiences aphonia, this

21. To optimise hypothyroidism treatment, (21) can

Look at the four texts, A – D, on pages 78 – 81.

For each question below, decide which text (A, B, C or D) the

You may use any letter more than once.

In which text can you find information about . . .

Anaemia is defined as an overall decrease in red blood cell mass. There

The common symptoms of all anaemias are those of hypoxia:

Weakness, fatigue, difficult or laboured breathing

There are many classification systems to differentiate anaemias. The most

Laboratory studies used to diagnose anaemia include:

A general diagnosis of anaemia can be determined by the following values:

Red blood cell amount

The treatment of anaemia depends heavily on the type of anaemia that

Identify and treat any complications that have occurred because of

7. What should vegan patients with vitamin deficiency anaemia be

8. If there is a decreased number of young red blood cells, what type of

9. How will a patient’s breathing sound when experiencing a significant

11. What is an increase in the number of reticulocytes an indication of?

15. Anaemia caused by (15) should be treated with a blood

17. If (17) is functioning properly, high reticulocyte anaemia is

18. A number of tests may be necessary to diagnose anaemia, due to the

19. Patients with anaemia caused by (19) should be instructed to

20. When identifying the type of aetiology, (20) of the patient

Take 4 minutes and 30 seconds to answer questions 1 – 3 below.

Continuity and coordination of care

The policy document tells us that a healthcare professional’s

(A) duty to care for a patient continues after a referral.

We first advise providers to verbally de-escalate and offer

Stage 1 (Mild) Hypertension 140–159 or 90–99

Stage 2 (Moderate) - 160–179 or 100–109

Stage 3 (Severe) Hypertension 180–209 or 110–119