PART A

TEXT A. Smoking and the Risk of Lung Cancer
For a life-long smoker, the risk of lung cancer is 20 times higher than a non-smoker. As with many of the health facts about smoking, this is an alarming statistic – but you can make a real difference to your health outcomes by choosing to quit smoking. Evidence shows that:
• If you quit smoking by the age of 40, you reduce your risk of lung cancer by up to 90%
• Quitting by the age of 50 reduces your risk by up to 65%
• After 10 years of being smoke-free, you’ll have avoided around 40% of the risk of ever getting lung cancer
• Even for someone newly diagnosed with early-stage lung cancer, quitting smoking improves prognosis and reduces the chance of tumour progression.

TEXT B: Cigarette packaging representations

Text C. Effect of Smoking on the Lungs
What does smoking do to my lungs? It paralyses and can destroy cilia, which line your upper airways and protect you against infection. It destroys the alveoli, or air sacs, which absorb oxygen and get rid of carbon dioxide. It destroys lung tissue, making the lungs less able to function, and irritates the lungs which creates phlegm and narrows the airways, making it harder to breathe.
How does that affect me? It makes you short of breath, it makes you cough, it gives you chronic bronchitis and repeated chest infections, it worsens your asthma and it can give you lung cancer. That’s apart from effects on your heart, fertility, pregnancy and your children.
But most people who smoke don’t get lung cancer. No. Most people die of other things first, often because they smoked.
If I give up, will my lungs improve? Yes. Cilia that are paralysed, but not destroyed, can recover. You will have less asthma and fewer chest infections. The sooner you stop, the better your chances of improved lung function.

Text D. Passive Smoking: Summary
• In Victoria, it is illegal to smoke in cars carrying children who are under 18 years of age.
• If a person who smokes can’t give up for their own health, perhaps the health of their partner or children, or other members of their household, will be a stronger motivation.
• Passive smoking increases the risk of respiratory illness in children, e.g., asthma, bronchitis and pneumonia.
• People who have never smoked who live with people who do smoke are at increased risk of a range of tobacco- related diseases, including lung cancer, heart disease and stroke.

PART A. For question 1-7, choose (A, B, C or D). In which text can you find information about
1 The effects of passive smoking?
2 The chances of a smoker getting lung cancer?
3 The benefits to the respiratory system of quitting smoking?
4 Ways to get help with quitting smoking?
5 The reduction in lung cancer risk if a smoker quits?
6 Recommended websites or phone numbers for smokers?
7 How smoking leads to particular symptoms?
Questions 8 – 14. Answer each of the questions, 8 – 14, with a word or short phrase from one of the texts.
8 How much of the lung cancer risk is avoided by being smoke-free for 10 years?
9 What is the phone number for Quitline?
10 What is normally expelled by the alveoli in the lungs?
11 What effect can smoking have on asthma?
12 What type of cancer can be improved by quitting smoking?
13 Which two (2) cardiovascular diseases are associated with passive smoking?
14 In which state is it illegal to smoke in cars carrying children under 18?
Questions 15 – 20. Complete each of the sentences, 15 – 20, with a word or short phrase.
• Each answer may include words, numbers or both. Your answers should be correctly spelled.
• Cigarette smoke damages the lungs by destroying the (15) _____________ that absorb oxygen.
• Eventually, the destruction of lung tissue can render a smoker unable to (16) _________ normally.
• Cigarette packets now feature depictions of its health effects, such as (17) _____________
• The effect of previous smoking can be reversed in some ways, as the (18) _____________ lining the upper airways can recover from damage.
Passive smoking increases the risk of (19) ________ in children.
• The good news is that if people (20) _____________ smoking before the age of 40, they can significantly reduce their cancer risk.

Part B. For questions 1 to 6, choose the answer (A, B or C) which you think fits best according to the text.

1. The treatment guidelines below recommend that
A. All patients receive parathyroid hormone monitoring
B. All patients receive 6-weekly monitoring
C. All patients receive baseline blood tests

Table: Medical Monitoring Guidelines for High-Risk Patients on Very Low Energy Diets

Assessment	Baseline Measures	6 weeks	Completion of Intensive Phase
Electrolytes/Creatinine	Yes	If required	Yes
Liver function tests	Yes	If required	Yes
Fasting glucose	Yes	If required	Yes
Cholesterol, triglycerides and HDL	Yes	If required	Yes
Uric acid	Yes	If required	Yes
Full blood count	Yes	If required	Yes
Iron studies	Yes	If required	Yes
Vitamin D	Yes	If required	Yes
Calcium and Parathyroid hormone (in patients on long-term anticonvulsants)	Yes	If required	Yes

2. This notice is giving information about
A. The 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. Infant with no clinical signs
1. Continue breastfeeding (approximately every 1–2 hours) or feed 1–5 mL/kg of expressed breastmilk or substitute nutrition.
2. Recheck blood glucose concentration before subsequent feedings until the value is acceptable and stable.
3. Avoid forced feedings (see above).
4. If the glucose level remains low despite feedings, begin intravenous glucose therapy.
5. Breastfeeding may continue during intravenous glucose therapy.
6. Carefully document response to treatment.
B. Infant with clinical signs or plasma glucose levels < 20– 25mg/dL (<1–1.4mmol/L)
1. Initiate intravenous 10% glucose solution with a minibolus.
2. Do not rely on oral or intragastric feeding to correct extreme or clinically significant hypoglycemia.
3. The glucose concentration in infants who have had clinical signs should be maintained at > 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 while weaning off the intravenous treatment until values stabilize off intravenous fluids.
7. Carefully document response to treatment.

3. This 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 management 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) recommends 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

4. This regulatory statement instructs healthcare professionals to
A. Admit all patients to NSW public hospitals within 48 hours
B. Assess all patients in the Emergency Department for VTE
C. Initiate VTE prophylaxis for all patients identified to be at risk

MANDATORY REQUIREMENTS:
• All adult patients admitted to NSW public hospitals must be assessed for the risk of VTE within 24 hours and regularly as indicated / appropriate.
• All adult patients discharged home from the Emergency Department who as a result of acute illness or injury, have significantly reduced mobility relative to normal state, must be assessed for risk of VTE.
• Patients identified at risk of VTE are to receive the pharmacological and / or mechanical prophylaxis most appropriate to that risk and their clinical condition.
• All health services must comply with the Prevention of VTE Policy.
• All Public Health Organisations must have processes in place in compliance with the actions summarised in the VTE Prevention Framework (Appendix 4.1 of the attachment). A VTE risk assessment must be completed for all admitted adult patients and other patients identified at risk, and decision support tools made available to guide prescription of prophylaxis appropriate for the patient’s risk level.

5. The advice below can best be applied to a healthcare setting by
A. The inclusion of nurses in governance structures
B. Providing information to patients in their native language
C. Redesigning projects according to advisory group recommendations

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

6. The purpose of the document below 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 emergency 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

PART C. TEXT 1. For questions 7 to 22, choose the answer (A, B, C or D)
SCOPE OF PRACTICE FOR HEALTHCARE PROFESSIONALS

A “scope of practice” refers to the procedures, actions, and processes that a healthcare practitioner is allowed to undertake according to their professional certification. The scope of practice is limited to that which is legally permitted for a healthcare professional with a certain level of education and experience, as well as their level of competency. Each level of jurisdiction has their specific laws, policies and licensing bodies, which define and regulate scope of practice. Different facilities, such as hospitals, may have different policies with regards to the clinical responsibility afforded to a healthcare professional.

There are two types of scope of practice. Core scope of practice refers to the everyday expectations of a clinician in practice, within that particular unit. These reflect the clinician’s qualifications and training and are considered to be “usual practice”. Advanced scope of practice refers to additional allowances or responsibilities, and usually specify particular treatments/procedures or categories of treatments/procedures to be included in the individual’s scope of practice.

Three categories may be useful in identifying a healthcare professional’s scope of practice. The first is education and training – has the person received formal or on-the-job training and have documentation to prove this? The second relates to the state or federal government that oversees the individual’s place of employment – does it allow the skill in question and not explicitly disallow it? Finally, the particular institution of employment is also relevant – does it also allow the skill in question and not explicitly disallow it?

Some examples of how scope of practice differs are useful. All states and provinces who recognise the licensing of registered respiratory therapists (RRTs) allow them to carry out extracorporeal membrane oxygenation (ECMO) support. However, some institutions do not allow this. In this case, it is within the institution’s rights to refuse to allow RRTs working there to perform ECMO. Therefore, RRTs working at these institutions are not allowed to include ECMO as part of their scope of practice.

Some environments require alterations to be made to a scope of practice. For example, allied health professionals who work in a rural or remote area have a broader scope of practice than those who work in metropolitan areas. They may be required to undertake activities or procedures that are outside the scope of practice generally accepted for their profession. This allows them to better meet the needs of communities in which they work.

Apart from geographical differences, certain significant events may also result in alterations being made to the scope of practice. For example, during the 2009 H1N1 influenza pandemic, a number of states expanded the scope of practice for a number of healthcare professions in order to increase the number of clinicians eligible to provide vaccinations. This was a temporary measure that lasted for the duration of the emergency and was legally permitted. Other states did not employ this measure, primarily because the capacity of clinicians to vaccinate the public in these areas was sufficient.

State governments annually review the scope of practice for routine (non- emergency) activities to make sure they are meeting the population needs. Changes to scope of practice must be considered with caution, as they can affect people in both positive and negative ways. Changes may be seen as a way to protect the public and give broader access to competent healthcare professionals, but can also result in turf battles between two or more different professions over the exclusive rights to perform an activity.

Considering this, healthcare professionals must understand their professional and individual scope of practice. Some tasks, while they are within the scope of practice for a profession, may not be permitted under the scope of practice of an individual. This is often an issue for allied health staff who move from rural or remote areas to metropolitan areas, where their scope of practice is more limited. Conversely, allied health staff who formerly worked in a metropolitan area may
find themselves without the skills or experience to meet their scope of practice in a rural or remote area. In the team environment of the healthcare system, it is key that each team member can clearly identify and communicate their professional and individual scope of practice.

Text 1: Questions 7 to 14

7. In the first paragraph, the meaning of the phrase “afforded to” is:
A. The clinical responsibility that is paid for by healthcare professionals.
B. The clinical responsibility that can be afforded by healthcare professionals.
C. The clinical responsibility that is given to healthcare professionals.
D. The clinical responsibility that is acceptable to healthcare professionals.
8. In the second paragraph, core scope of practice refers to:
A. The clinician’s expectations of what their work involves.
B. The things that a member of the public can expect from the clinician.
C. The things that the unit can expect from the clinician.
D. The qualifications and training of the clinician.
9. All of the following are categories that can be applied to identify scope of practice except:
A. The formal or on-the-job training received by the healthcare professional.
B. The state or federal government’s allowance or non-allowance of an activity.
C. The institution’s allowance or non-allowance of an activity.
D. A proven history of formal or on-the-job training.
10. The situation for paramedics is similar to that for registered respiratory therapists because:
A. They are both involved in emergency patient care.
B. They both have varying scopes of practice.
C. They can both perform a percutaneous cricothyrotomy.
D. They are both procedures used to help a patient breathe more effectively.
11. According to the fifth paragraph, the benefit of changes to scope of practice is:
A. The communities in which healthcare professionals work can have their needs met more effectively.
B. The services provided by allied health professionals in rural or remote areas can be better than those provided in metropolitan areas.
C. Allied health professionals can better serve rural or remote communities.
D. Healthcare professionals can rely more on their judgment when treating patients, rather than being restricted by their scope of practice.
12. In the sixth paragraph, the author implies that:
A. Some states and provinces were better equipped to prevent the spread of H1N1 influenza in 2009 than others.
B. Healthcare professionals should have their scope of practice extended permanently to provide vaccinations in case of another influenza pandemic.
C. There was a knee-jerk reaction by some states to contain the spread of H1N1 influenza in 2009 by expanding their capacity to deliver vaccinations.
D. In some states, healthcare professionals have been allowed to provide vaccinations since 2009 to prevent the spread of pandemic influenza.
13. According to the seventh paragraph, the author’s opinion on changes to scope of practice is that:
A. Such changes are necessary to protect the public and provide access to a broader range of competent healthcare professionals.
B. Such changes can be politically controversial and have an ambiguous benefit.
C. Such changes lead to conflict between two or more healthcare professions over the exclusive rights to perform an activity.
D. Such changes should be reviewed more frequently than they are currently.
14. The main message of the article is:
A. Scope of practice varies within each profession, so healthcare professionals should be informed of what their scope of practice is.
B. Scope of practice is dynamic and depends on geographical factors, individual states or institutions, and significant events.
C. Different healthcare professions have different scopes of practice.
D. Each member of a healthcare team should be aware of their individual, as well as professional, scope of practice.

PART C- TEXT 2. Advanced Dementia

Dementia is a significant cause of morbidity and mortality worldwide. In 2014, approximately 5 million people in the United States had a diagnosis of Alzheimer’s disease, with an estimated 14 million being affected by 2050. Once diagnosed, patients can survive with the condition for an average of 3 to 12 years. The majority of this time will be spent in the most severe stages of the disease. As nursing homes are the site of death in most cases, these are an important factor to consider when studying Alzheimer’s disease.

At the moment, no cure exists for dementia or the progression of its disabling symptoms. The Global Deterioration Scale, which ranges from 1 to 7, is used to describe the level of disability in patients with dementia. Stage 7 characterises advanced dementia: profound memory deficits, a virtual absence of the ability to verbalise, inability to ambulate independently or perform activities of daily living, and urinary and fecal incontinence. These manifestations result in complications such as eating problems, episodes of fever and pneumonia.

In order to provide an estimate of survival time for patients with dementia, the Functional Assessment Staging Tool is commonly used. Although impossible to quantify accurately in 100% of cases, this tool allows a general prognosis to be made. This is important because a patient’s eligibility for the hospice benefit is assessed based on their projected survival time as well as history of dementia- related complications. Some clinicians prefer to use a risk score to predict survival, as this has slightly better predictive ability. Many consider that the eligibility of patients for nursing home care should be based on the desire for such care, rather than prognosis.

The care of patients with advanced dementia revolves around advanced care planning. This includes educating the patient’s family about the prognosis of the disease and its manifestations, counseling about proxy decision making, and recording the patient’s wishes regarding treatment through an advanced care directive. Some observational studies have shown that patients with advanced care directives have better palliative care outcomes: reduced incidence of tube feeding, fewer hospitalisations during the final stages, and greater likelihood of enrollment in a hospice.

Decisions about the care of patients should also reflect the goals of such care. These goals should be agreed upon between the provider, the primary carers, and ideally, the patient themselves. The goals of treatment, and therefore the treatment decisions themselves, should be aligned with the patient’s wishes as far as possible. An example of how treatment preferences may vary is whether the patient would like all medical interventions deemed necessary, only certain medical interventions, or comfort measures only. In 90% of proxies interviewed in prospective studies, the latter was reported to be the primary goal of care.

Out of the most common complications of advanced dementia, eating problems are the most prevalent. These may include oral dysphagia (“pocketing” of food in the cheek), pharyngeal dysphagia (inability to swallow, leading to the risk of aspiration), inability to eat independently and refusal. When eating problems occur, acute causes should always be considered (e.g., dental pathology). The reversal of such causes should be guided by the previously agreed goals of care. Chronic or sustained eating problems are most often managed by hand feeding, tube feeding, or encouragement of food intake through smaller meals, different textures or high-calorie supplementation.

Infections are another common clinical problem in patients with advanced dementia, most commonly relating to the urinary or respiratory tract. In 362 nursing home residents with advanced dementia, the Study of Pathogen Resistance and Exposure to Antimicrobials in Dementia (SPREAD) found that two thirds were diagnosed with suspected infections within a 12-month period. Approximately 50% of patients with advanced dementia are diagnosed with pneumonia in the last 2 weeks of life, and such patients experience a high rate of death from this cause. However, the use of antimicrobials to treat infections has been found to increase length of survival but also the level of discomfort in patients with advanced dementia. Therefore, such treatment may not necessarily align with the patient’s preferences or goals of care.

Improving the care of patients with advanced dementia is becoming an increasingly recognised issue amongst healthcare providers. Studies of the experiences of patients with advanced dementia have shown that care which is focused on patient-centred goals and adherence to patient preferences is most effective in improving outcomes. In order to achieve this, providers need to be better equipped to engage patients and their families in advanced care planning, reduce the use of invasive treatments of limited benefit (such as tube feeding) and better address distressing clinical symptoms.

Text 2: Questions 15 to 22

15. The Global Deterioration Scale is most useful for providing healthcare professionals with information about:
A. The patient’s ability to recall memories, verbalise, ambulate independently, attend to activities of daily living and control urine and fecal output.
B. A quantification of the patient’s degree of disability.
C. The likelihood of dementia-related complications.
D. The patient’s predicted survival time.
16. According to the third paragraph, the main reason for making a general prognosis about survival time is:
A. To provide family members with some idea of the trajectory of the disease.
B. To inform decisions that providers must make about treatment.
C. To determine eligibility for nursing home care.
D. To determine eligibility for the government subsidy of hospice care.
17. The best replacement for the word “proxy” in the fourth paragraph would be:
A. Substitute B. additional C. carer D. treatment
18. In the fifth paragraph, the author’s main argument is that:
A. Decisions about care should be guided by its goals, which most often means comfort care rather than medical interventions.
B. Most patients with advanced dementia prefer comfort care to medical interventions.
C. The goals of care should be agreed upon in consultation with the provider, the family and the patient themselves.
D. Treatment preferences vary between individual patients with advanced dementia.
19. According to the sixth paragraph, eating problems in advanced dementia may be caused by:
A. inappropriate eating practices.
B. recent dental procedures.
C. aspiration of food.
D. refusal to eat independently.
20. In the seventh paragraph, the author suggests that:
A. About 50% of people with advanced dementia will suffer from pneumonia during the last 2 weeks of their life.
B. Infections in people with advanced dementia should not always be treated.
C. Within a 12-month period, approximately two thirds of nursing home residents with advanced dementia are suspected to have an infection.
D. Urinary and respiratory infections are the most common clinical problem in advanced dementia.
21. Ways in which the care of patients with advanced dementia can be improved include all the following except:
A. Adherence to patient preferences for treatment.
B. Better treatment of distressing symptoms.
C. Engaging patients and families in advanced care planning.
D. Hand feeding instead of tube feeding.
22. The author’s approach to the care of patients with advanced dementia could best be described as:
A. practical. B. patient-centred. C. analytical. D. utilitarian.

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