TEXT A:
• People with a history of acute rheumatic fever (ARF) and a diagnosis of rheumatic heart disease (RHD)
• Aboriginal and Torres Strait Islander people (children aged between 5 and 14 are most at risk) and immigrants from developing countries
• Increased cardiac load during pregnancy will exacerbate pre-existing rheumatic valvular heart disease
• Importance of early diagnosis and regular secondary prophylaxis will help prevent deterioration of disease to a point where pregnancy is a risk
• Secondary prophylaxis is safe and should be continued during pregnancy
• Antibiotic prophylaxis to prevent endocarditis if prolonged labour and/or ruptured embranes
• Pre-conception counselling and assessment for all women with known rheumatic valvular disease
What is rheumatic heart disease (RHD)?
• When a person becomes infected by Group A Streptococcus bacterium (GAS), the immune response can cause acute generalised inflammation that affects the heart, joints, brain and skin. This is called acute rheumatic fever (ARF)
• Recurrent ARF can cause permanent damage to the heart valves – most commonly the mitral and aortic valves
• This damage is known as rheumatic heart disease (RHD)
• RHD can be classified as mild, moderate or severe
• In a mild case there will be no clinical evidence of heart failure
• In severe cases there are signs of valvular disease, oedema, angina and syncope

TEXT-B. Table 1. Classification of rheumatic heart disease
Class	Definition of category
HX ARE or no RHD. Priority 4.	• No pathological mitral or aortic regurgitation, but may have minor morphological changes to mitral or aortic valves on echocardiography
Mild RHD. Priority 3.	• Mild mitral or aortic regurgitation clinically and on echocardiography, with no clinical evidence of heart failure, and no evidence of cardiac chamber enlargement on echocardiography
Moderate RHD. Priority 2.	• Any valve lesion of moderate severity clinically (e.g., mild moderate cardiomegaly and/or mild – moderate heart failure) or on echocardiography • Mild mitral regurgitation together with mild aortic regurgitation clinically or on echocardiography • Mild or moderate mitral or aortic stenosis • Any pulmonary or tricuspid valve lesion co-existing with a left-sided valve lesion
severe RHD. Priority 1.	• Any clinically severe valve lesion (e.g., moderate to severe cardiomegaly Or heart failure) on echocardiography • Any impending or previous cardiac valve surgery

TEXT C: Management
• The fundamental long term goal to manage RHD is to prevent ARF recurrences and therefore prevent the progression of valve disease
• This is achieved by regular delivery of secondary prophylaxis with intramuscular LA Bicillin
• Where adherence to secondary prevention is poor there is greater need for surgical intervention and long term surgical outcomes are poor
Client education and health promotion
• Discuss what RHD is, how it progresses and its association with throat and skin infections
• Recognizing the signs and symptoms of recurrent ARF and of RHD
• The need for timely access to health services and follow up
• Encourage the client to identify barriers to adequate lifestyle modification and medical adherence and to set goals to overcome those barriers based on their capacity and
understanding
• Provide relevant service and educational resources
Social emotional support
• A self- or clinician-rated mood scale can be used to assess for altered moo. Rating scales should be supplemented by a clinical assessment by suitably qualified mental health clinician to make a diagnosis
• Acknowledge any client concerns and reassure them that good adherence to appropriate treatment can improve the symptoms of their condition
Secondary prophylaxis (antibiotics)
• All clients with evidence of RHD and a history of ARF should have secondary antibiotic prophylaxis to control streptococcal infections
• Discuss the effectiveness of Bicillin regimes to prevent recurrence of ARF and minimize RHD
• Consider adverse reactions to medications
Regular physical health and specialist review
• Follow the care plan for RHD, Access to timely specialist physician, paediatric and/or cardiologist services for examination of heart and lungs
• Echocardiography
• Examination of throat, teeth and skin every presentation
• Assessment for shortness of breath, ankle swelling, palpitations or dizziness and chest pain
Dental care
• The risk of infective endocarditis and further heart valve damage increases with poor dental hygiene and oral infections
• 6 – 12 monthly dental care (depending on classification level) is essential for clients with a history of ARF and RHD
• Discuss dental hygiene and oral health at each visit
• Where appropriate, antibiotic prophylaxis are given prior to dental procedures
• A dental assessment and any treatment is required prior to valvular surgery
Recall and review
• Place client on a facility ARF/RHD recall system
• Provide client with the date of the next scheduled Bicillin injection
• Recall client from 21 days after the last injection to ensure that injections are given no more than 28 days apart
• Provide the client and other health services with Bicillin prophylaxis details when client is travelling to different communities
Surgery
• Surgery is determined by the severity of damage to the heart valves (severe RHD)
• Early referral to a cardiologist is required to identify heart failure and consideration for valve repair
• Repair or replacement of damaged heart valves prevents left ventricular dysfunction and severe pulmonary hypertension
• Heart valve replacement risks include stroke and infective endocarditis

TEXT-D: Medications
• Primary prophylaxis involves prompt treatment with antibiotics for treatment of streptococcal infection
• Secondary prophylaxis involves regular administration of Bicillin to prevent recurrent ARF
Secondary prophylaxis
• Decisions to cease secondary prophylaxis should be based on clinical and echocardiographic assessment by a specialist ARF/RHD physician
• All persons with
––ARF or RHD should have prophylaxis for a minimum of 10 years after most recent episode of ARF or until age 21 years (whichever is longer). Clients > 25 years of age who are diagnosed with RHD, without any documented history of prior ARF, should receive prophylaxis until the age of 35 years and then
––no RHD or mild RHD, if clinically assessed by echocardiography can discontinue prophylaxis at this time
––moderate RHD continue prophylaxis until 35 years of age
––severe RHD continue prophylaxis until 40 years of age. Although the risk of recurrence is extremely low in people aged > 40 years, in some cases prophylaxis may be continued beyond the age of 40 years, or even for life e.g. when a client decides they want to reduce even a minimal risk of recurrence

Table 2. Antibiotic regimens for secondary prevention
Antibiotic	Dose	Route	Frequency
First line
Benzathine penicillin C (Bicillin)	≥20 kg 900 mg (1,200,000 U) <20 kg 450 mg (600,000 U)	Deep 1M injection	28 days
Second line
If 1M route is nol possible or refused • Adhprpncp shoul d bp carefully monitored • Oral secondary prophylaxis is nowhere near as effective as Bicillin
Phenoxymethylpenicillin (Penicillin V)	250 mg	Oral	Twice daily
Following documented penicillin allergy
Erythromycin	250 mg	Oral	Twice daily

For 1-7, decide which text (A, B, C or D) the information comes from.
1. Classification of RHD
2. Steps to be taken when assessing a patient
3. Providing proper medicines
4. How to determine a patient with RHD
5. High risk groups
6. Giving support to patients
7. Counseling and assessment for women
Questions 8-13. Complete each of the sentences, 8-14, with a word or short phrase from one of the texts.
8. Heart valve substitution dangers include _______________ and infective endocarditic.
9. _______________ to continue, when a client decides they want to reduce even a minimal risk of recurrence over 40 years of age.
10. The prevention of recurring Acute Rheumatic Fever is achieved by regular delivery of secondary prophylaxis with _______________
11. _______________ months of dental care is essential for a patient with history of ARF/ RHD
12. Moderate RHD has been given the _______________ priority
13. No evidence of _______________ can be identified in person identified with mild RHD
Questions 14-20. Answer each of the following questions, 15-20, with a word or short phrase.
14. If IM route is not possible or refused to take medicines, what antibiotic is used to treat?
15. The ultimate aim of RHD is to prevent?
16. If a patient identified with mild rheumatic heart disease while review, what to discontinue
17. Which heart valves will damage, if RHD is attacking again and again?
18. When does a doctor can assess and give the patient Priority 1 of RHD?
19. What should have done prior to Valvular surgery?
20. What involves in Secondary prophylaxis to prevent recurring Acute Rheumatic Fever

PART B. Choose the answer (A, B or C) which you think fits best according to the text.
1. What does this manual extract tell us about?
A. To project I-dopa is not an ideal drug for long term treatment.
B. Treatment is not always ideal for Premature Parkinson’s disease
C. To project that the I-dopa is very effective in removing brain cells
Treatment: Treatment isn’t always needed in the early stages of Parkinson’s disease – mild tremor, for instance, may be inconvenient and cause social embarrassment but otherwise life can go on pretty much as normal. As the disease progresses, it will usually be treated with drugs. Several different drugs are available. These drugs act to increase signally within the dopamin pathways in the basal ganglia.
The best known of these is levodopa, also called l-dopa. When this drug was introduced in the 1960s it was a revolution in the treatment of Parkinson’s disease. It crosses easily from the bloodstream into the brain tissue, where it is converted by surviving brain cells to become dopamine. The symptoms of tremor and rigidity are often dramatically improved. The effect of the drug is not as potent in patients after several years of treatment as fewer remaining brain cells are able to convert the l-dopa to dopamine.

2. Where to use panic door exit devices:
A. Public buildings, visitor rooms
B. Smoke control rooms, schools.
C. Community centers, schools, and hospitals.
EMERGENCY EXIT DOOR PANIC DOORS: In panic situations the safety and rescue possibilities for people in the building are the main concern. In Europe uniform standards for emergency exit door fittings are in application.
Within the meaning of these standards, emergency exit door systems are subdivided in emergency exit devices according to EN 179, and panic door Exit devices according to EN 1125. Emergency exits acc. to EN 179 are designated to buildings to which the general public does not have access and whose visitors understand the function of the emergency doors.
Panic door exit devices acc. to EN 1125 are used in public buildings where the visitors are not familiar with the function of emergency doors, like schools, hospitals, shopping malls. The WICSTYLE door systems offer a comprehensive range of applications, which can also be combined with other functions and design options.
TECHNICAL PERFORMANCE. Profile technology:
• Doors in accordance with EN 179 (emergency Exit devices) or with EN 1125 (panic exit devices)
• Many system options for the emergency application, allowing for a unified door design within the building, irrespective of additional functions
• Single or double leaf possible
• Combination with burglar resistance in classes RC1 and RC2 possible
• Execution in combination with fi re protection in classes T30 and T60 and in combination with smoke control possible (national regulations must be respected)

3. What led for confrontation in resolving patient’s grievances or complaints by many organizations?
A. Lack of uniform rules across the country in dealing with complaints
B. No clear guidelines for channeling patients’ grievances to appropriate
C. Overriding the guidelines lay down by CMHCs.
Responding to complaints and grievances: Requirements for certain providers: Certain entities participating in Medicare and Medicaid are required to have specific grievance policies and procedures.
For example, under the Centers for Medicare and Medicaid Services’ (CMS) Conditions of Participation for Community Mental Health Centers (CMHCs) , CMHCs must inform clients that they have the right to voice grievances. CMHCs must also distribute written information to clients on filing a grievance during the patient’s initial evaluation. Although the Conditions of Participation for CMHCs only apply to a narrow subset of community behavioral health organizations, the standards are similar to expectations related to client rights in many states.
For hospitals, CMS’ Conditions of Participation require more in terms of a specific patient grievance process, including suggested time frames to investigate, resolve and follow-up on grievances. CMS also differentiates between a “complaint” and a “grievance.” While many organizations use these terms interchangeably, the definitions/distinctions laid out by CMS can help to determine the appropriate response when a patient makes a complaint or grievance.

4. The purpose of these notes about a counseling agent is
A. To aid and advice patient’s caretakers at home
B. To consider various aspects while treating a patient
C. Modify himself as patient’s caretaker.
Counseling: a Service to Society: Counselors advise and assist individuals, families, groups and organizations. The American Counseling Association describes counseling as a collaborative effort between counselors and their clients. To be an effective counselor, a trained professional needs to be able to work on numerous levels. For example, counselors help people of all ages identify problems, strengths and goals; work through issues; improve interpersonal and coping skills; address mental health concerns; change behavior and focus on personal growth.
Often, when one person is seeing a counselor, the effect goes beyond what the individual gains. Families and family dynamics are affected when someone who has been grappling with difficult problems begins working with a trained counselor. As the individual client learns what is causing her distress and how to manage it, family members open to evolving may benefit from knowledge, understanding and improvements acquired through counseling sessions. Other beneficiaries include extended family, employers, colleagues and friends, community groups and society.

5. What we understood form the manual extract is
A. Technological progress made product delivery easy to the required.
B. Digital copies made user friendly for the Nurses despite costly
C. Criticism in Manuals will not be the sole criteria in evaluating writer’s works.
Medical device user manuals: Shifting Towards Computerization: Consider the challenges facing technical communicators (i.e., technical writers) who design and produce medical device user manuals: First, their work must address the needs of an especially diverse audience, starting with caregivers and extending to trainers, biomedical engineers, sales personnel, government regulators, and many others. Because of its broad potential audience, the typical medical device user manual must be several documents in one. Second, technical communicators often have only limited resources and time to produce high-quality manuals as their companies speed products to market. Third, a user manual’s primary audience—arguably the nurses, physicians, and technicians who deliver direct care to patients—tend to prefer engaging in hands-on training over reading user manuals. The popularity of the hands-on approach creates a perception of user manuals as perfunctory—a perception that could take the wind out of any technical writer’s sails.
As computer technology grows ever more ubiquitous, a popular trend toward computerizing learning tools is cause for new excitement among technical communicators and allied professionals alike. As more caregivers gain computer access, the practicality of their viewing instructions on a medical device’s computer display, on the Web, or on an interactive CD-ROM, for example, will increase. Such technological progress will enable content developers to think beyond the printed page and embrace alternative delivery mechanisms that may be more compatible with a particular user’s learning style. In addition to the benefits it might afford users, computerization will assist manufacturers in updating content as readily as they install new versions of software into devices. As a result of this emerging multimedia approach, the hard-copy medical device user manual is swiftly evolving toward a system of both print and electronic components.

6. Nursing registration guidelines states that
A. A nurse has to complete her full education in vocational schools
B. To proclaim as a registered Nurse, she has to complete preregistration program study.
C. 5 years full term course completion is the only the criteria for registering as a Nurse.
Registered nurses and registered midwives: If you are applying for registration as a registered nurse and/or a registered midwife, you must provide evidence of the completion of five (5) years*(full-time equivalent) of education taught and assessed in English, in any of the recognised countries.
NOTE: a) The Board will only accept the completion of five (5) years* (full-time equivalent) of:
i) tertiary and secondary education taught and assessed in English; or
ii) tertiary and vocational education taught and assessed in English; or
iii) combined tertiary, secondary and vocational education taught and assessed in English; or
iv) tertiary education taught and assessed in English from one or more of the recognised countries listed in this registration standard.
b) The five (5) years referred to in paragraph a above must include evidence of a minimum of two (2) years full-time equivalent pre-registration program of study approved by the recognised nursing and/or midwifery regulatory body in any of the recognised countries listed in this registration standard.

PART C. TEXT 1. Choose the answer (A, B, C or D)
When health anxiety set my mind (and heart) racing. ” You’re too young to be here.”
I couldn’t agree more. I look around the cardiologist’s waiting room, guessing that I’m the youngest person by at least 20 years. Everyone else is slightly crumpled; soft, wrinkled and grey. But, despite my youthful vigour – well, maybe slightly worn around the edges after 39 years – I did need to be there. You see a month or so prior to my walking into the waiting room, my heart had started doing something weird. Every now and then – roughly every 10 or 20 minutes – it would do an extra big beat, or an odd beat, or something like that. I discovered that it’s hard to listen to your own heart. It’s a bit like a quantum physics problem: the act of observing it changes its behaviour. For a few weeks, I ignored it, thinking it was probably related to the horrible cold I was experiencing.

But it continued. And continued. So I did what all internet-equipped hypochondriacs do, I consulted Dr Google. Being a health journalist whose search history tends to demand the good stuff, I like to think that I found some slightly more authoritative and less hysterical sources than your average search would hand up; but it was still enough to make me decide a trip to the doctor was in order. My GP couldn’t find anything. My blood tests were normal, my ECG healthy, so he sent me to a cardiologist. It wasn’t an urgent referral, so I was faintly reassured that the GP wasn’t worried that I was going to do the clutch-heart-and-drop Hollywood thing just yet. Then I had to wait. It was two weeks between seeing the GP and my cardiology appointment, and for the first time in my life, I experienced something that I have read and written about so often: the anxiety of the so-called ‘worried well’.

This is one of the reasons why, even though we have so many tests for so many diseases, we don’t use them on everyone. Because while a test might pick up one person in a hundred with a medical problem (which may not even have been life-threatening), for the other 99 people in that population, the time between having the test and getting the all-clear is for many a time of great anxiety and stress. For many, that stress will be in the background. We might not even be aware of it, but no matter how bullet-proof we try to convince ourselves that we are, ultimately, we’re all waiting for the bomb with our name on it. It will, on some level, eat away at our psyche.

While there’s no blood test or sliding scale to really quantify that stress, it is real, and it is a cost. During this time I had lunch with a dear friend, who was off to get a lump in her breast checked. Our faces mirrored each other’s unspoken anxiety over our obscenely large midday breakfasts. We talked about the fact that ultimately, everyone has to die of something. I said, “Somehow, I don’t think my ticker and your bosom are it for us,” probably sounding a lot more confident than I felt. Lying in bed at night, I would listen intently for my heart’s occasional mega-thump, trying to glean just a little bit more information from the errant beats that might reassure me this wasn’t atrial fibrillation or a dangerous arrhythmia. Instead, my heartbeat began to sound faster and louder than I had ever noticed before. Even when I tried to ignore it and go to sleep, it pounded in my chest like the war drum of Impending Doom.

Finally, the day comes for my trip to the cardiologist. The night before, I’m plagued with intensely stressful dreams, including one in which I’m due to perform on stage right after Tim Minchin. If that isn’t a hard act to follow, I don’t know what is. I wake up with my guts tight, possessed with a slightly hysterical mania that sees me charging around the house, washing, cleaning, tidying. I get the kids out the door for school earlier than usual, much to their and my confusion at the lack of the usual screaming “HURRY UP!” routine. The cardiologist is running late, so I have nearly an hour in the waiting room watching other patients shuffle in and out of the rooms. My heart flip-flops regularly, reassuring me that I’m not going to be wasting his time.

The nurse beckons me in for my stress test. My chest is decorated with sticky dots, like I’m waiting to be digitally rendered as a female Gollum, and I’m connected to a tangle of electrical leads. Then up onto the treadmill, and my test begins. Oh, the irony. My heart problem has stage fright. The nurse cranks up the treadmill until I’m puffing and sweating under the heavy ECG belt, yet my recalcitrant heart steadfastly refuses to give even a single performance of its aberration. Instead, it defiantly beats strong, solid, and regularly, as if trying to prove that it’s all simply a product of my paranoid imagination.

Even after the test is finished, and I’m cooling off in the waiting room while the doctor reviews the results, my heart beats as reliably as an atomic clock. Despite the absence of anything on the ECG, he diagnoses me as having ventricular ectopic beats. These are occasional misfiring, like an extra heartbeat that happens in the lower chamber of the heart (the ventricle). In otherwise healthy individuals, they are no cause for alarm. In fact, they reassure me that my heart is healthy enough that I could apply for a job with police rescue.

He schedules an echocardiogram to check there’s not some other valve weirdness going on, but by that stage I’m skipping out the door, feeling like a possible death sentence has been lifted and instead I’m contemplating doing a half-marathon for the first time in my life.

7. Why does she heard the words “you’re too young to be here”
A. Because she is not having any problem
B. She is healthy, so, not to come there
C. They think her age is not ideal to have problems
D. It is an restricted area for minors
8. Why the author does compare her increased heartbeat with quantum physics?
A. Probably it was her perception that she had high heartbeat
B. She overwhelmingly responded to the difficult problem in physics
C. Used in the context of her ideas to actions conflicting in her mind.
D. Unable to define a proper form, instead she used.
9. Why she delayed to consult Cardiologist?
A. She thinks it’s unnecessary
B. She was willing consult another GP, instead cardiologist
C. Because it was not an urgent referral
D. Undermined the importance of referral
10. Why she used the words “worried well” in the second paragraph?
A. She is afraid of what going to face, when she meet cardiologist.
B. She is anxious to meet cardiologist
C. It is hard to digest, until she gets positive report
D. Worried to get appointment after two weeks
11. What do you understand from the last sentence in the third paragraph?
A. Stress cannot be in varied from person to person
B. It projects surprisingly at sometimes
C. Stress cannot be hidden at all times
D. Nothing
12. Why does she talk about some quoted words in the fifth paragraph?
A. To regain their confidence
B. To refrain from stress
C. To mobilize themselves to meet doctor regularly
D. To verify that theirs GP have referred correctly
13. The word “Beacons” means
A. Searches B. Signs C. Signals D. Warns
14. Who does the word “they” refers to?
A. Doctors B. Cardiologists C. Nurses D. Patients

PART C. TEXT: 2
News reports about a study from Germany may provide the ultimate excuse for men to dress more casually for work, finding neckties reduce blood supply to the brain.

The study showed that wearing a tie that causes slight discomfort can reduce blood flow to the brain by 7.5 per cent, but the reduction is unlikely to cause any physical symptoms, which generally begin at a reduction of 10 per cent. Past research shows that compression of the jugular vein in the neck reduces blood flow to the brain. In this new study, published recently in the journal Neuroradiology, the researchers tested whether the pressure of a necktie could induce these changes.

They recruited 30 young men aged 21 to 28 years and split them into two groups: those wearing neckties and those without. Using magnetic resonance imaging (MRI), the researchers tested the cerebral blood flow (total blood flow to the brain) using a technique that showed changes to the flow via a colour change. They also tested the blood flow from their jugular vein.

The first MRI took a “baseline” scan, while the participants in both groups had an open collar (and those in the tie-wearing group had a loosened tie). For the second scan, the men’s collars were closed and participants in the tie group tightened their Windsor knot until they felt slight discomfort. A third scan followed, in the same conditions as the baseline scan. All scans lasted 15 minutes.

The authors found that wearing a necktie with a Windsor knot tightened to level of slight discomfort for 15 minutes led to a 7.5 per cent drop in cerebral blood flow, and a 5.7 per cent drop in the 15 minutes after the tie was loosened. The men’s blood flow in the control group — those who weren’t wearing a tie — didn’t change. No change was found in jugular venous flow between the two groups.

The study didn’t go into any detail about the effects, so let’s consider what they might be. The researchers found a reduction in blood flow to the brain of 7.5 per cent, which is unlikely to cause problems for most men. Healthy people are likely to begin experiencing symptoms when blood flow to the brain reduces by about 10 per cent — so, a larger reduction than the study found. Along with an increase in blood pressure at the site, a 10 per cent reduction in blood flow can cause dizziness, light-headedness, headaches and nausea. But even with a 7.5 per cent drop in blood loss to the brain, a person could still experience some temporary dizziness, headaches or nausea.

Compounded with other factors, such as smoking or advanced age, a 7.5 per cent decrease could bring some people over this 10 per cent threshold of blood flow loss, placing extra stress on their already strained bodies and increasing their risk of losing consciousness or developing high-blood pressure. It’s unclear why there was no change to the jugular, but this may be due to the circular nature of the restriction: the pressure is equally distributed across the neck, rather than just the jugular.

Further research is needed to assess the impact of wearing a tie for longer periods and wearing different knots. Any pressure on the neck is slightly discomforting, and men’s style guides advise tightening a necktie to be “tight but not too tight”. Whether this tightness aligns with the participants’ classification of “slight discomfort” is unclear. This study had a sample size of 30 participants, which is relatively small. Most human studies investigating blood pressure and cerebral blood flow have at least 40 to 60 participants.

Another limitation is that the study did not include a discussion about the potential impact of the blood restriction, or the finding that jugular blood flows didn’t change. But overall, the study is simple and well-designed. It adds to a small but growing body of research about the problems with neckties: they can lead to higher rates of infection, as they’re infrequently washed; and they may increase intraocular pressure (blood pressure in the eyes) to the point of increasing the risk of glaucoma.

Perhaps it’s time to get rid of this unwelcome guest from our wardrobe, or restrict it to special occasions.

15. As per the new study report on using neckties by professionals will result in
A. Causing pain to Brian
B. Causes physical changes
C. Will not have major impact on blood supply to brain
D. No relation in causing physical symptoms.
16. How the researchers identified the blood flow change to brain
A. By using a specially designed meter
B. Based on colour
C. With the help of nerves blood flow density
D. Based on samples collected from research
17. The word ‘Baseline’ defines that
A. The first scan was taken as referral mark
B. They considered it as the minimum level to conduct the research
C. It was considered as the highest level to check
D. It was the first stage in process
18. What was the researcher’s conclusion at the end?
A. There was the change of color in blood flow to brain
B. Identified no relation to jugular venous flow
C. Had developed a new technique to check this instead
D. It was a disappointing result for them
19. What will cause, if an aged patient using his necktie continuous for 2-3 hours?
A. May develop additional symptoms to the existing
B. Will develop resistance to blood flow to brain
C. Nothing will happen in prolonged exposure
D. Unable to determine the impacts
20. What was the major limitation in study report?
A. It doesn’t include many other aspects of the study
B. It focuses mainly on analyzing the impact of jugular venous flow.
C. It includes only a small group of people
D. Lack of technical support.
21. What does the word “it” refers to?
A. The study
B. The jugular venous flow
C. Blood flow
D. Infection
22. What does the word “this” refers to?
A. Necktie B. Infection C. Blood pressure D. Research

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