Rart A

Fractures, dislocations and sprains: Questions

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

Simple Fracture of Limbs

Immediate management:
• Halt any external haemorrhage by pressure bandage or direct pressure
• Immobilise the affected area
• Provide pain relief
Clinical assessment:
• Obtain complete patient history, including circumstances and method of injury
- medication history – enquire about anticoagulant use, e.g. warfarin
• Perform standard clinical observations. Examine and record:
- colour, warmth, movement, and sensation in hands and feet of injured limb(s)
• Perform physical examination
Examine:
- 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

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
Morphine Ampoule 10 mg/mL IM/SC Adult only: 0.1-0.2 mg/kg to a Stat
max. of 10 mg Further
doses on
Adult only: MO/NP
IV Initial dose of 2 mg then order
(IHW may not 0.5-1 mg increments slowly
administer IV) repeated every 3-5 minutes if
required to a max. of 10 mg

Use the lower end of dose range in patients ≥70 years.

Provide Consumer Medicine Information: advise can cause nausea and vomiting, drowsiness.
Respiratory depression is rare – if it should occur, give naloxone.

Text D

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 jewelry 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.

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.

In which text can you find information about

1 procedure for delivering pain relief? --------------------------------

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

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?

------------------------------------------------------------------------------------------------------------------

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?

------------------------------------------------------------------------------------------------------------------

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

repeated analgesia?

------------------------------------------------------------------------------------------------------------------

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.

15 Falling on an outstretched hand is a typical cause of a ---------------------------------------- of the elbow.

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.

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.

B. may not work correctly in close proximity to some other devices.

C. should be considered safe to use in all hospital environments.

Instruction Manual: Digital Automatic Blood Pressure Monitor

Electromagnetic Compatibility (EMC)

With the increased use of portable electronic devices, medical equipment may be susceptible
to 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 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.

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 authorized.
C. which staff should perform NG tube placement.

NG feeding tubes

Displacement of nasogastric (NG) feeding tubes can have serious implications if undetected.
Incorrectly 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 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 competent. Assistant
practitioners and other unregistered staff must never insert NG tubes or be involved in the initial
confirmation of safe NG tube position.

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

'Right Patient, Right Blood' Assessments

The administration of blood can have significant morbidity and mortality. Following the introduction
of the '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 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 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 Training Matrix.

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.

Extract from ‘Chaperones: Guidelines for Good Practice’

A patient may specifically request a chaperone or in certain circumstances may nominate one, but it
will 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 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 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 specifically requests the chaperone to remain.

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.

Annual medication review

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.
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 problems about their medicines’ and that ‘any
changes resulting from the review are agreed with the patient’.
It also states that GP practices are expected to
• minimize 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
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.

To:
All Staff

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 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 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 44% were respiratory related and more than 35%
occurred on the general care floor. It is therefore recommended that post-operative patients now
have continuous monitoring, instead of spot checks, of both
oxygenation and ventilation
 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 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, things go wrong.’

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 the patient’s reaction time, mood, and judgement all
suffering if they are kept awake too long.

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 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.

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.

Within the brain, scientists have glimpsed signs of physical damage from sleep loss, and the time-line for
recovery, 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 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 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.

Further insights could be drawn from the study of shift workers and insomniacs, who serve as natural
experiments 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.

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.

8. What do we learn about sleep in the second paragraph?

A. Scientific opinion about its function has changed in recent years.

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.
D. Studies undertaken in the past have formed the basis of current research.

9. What particularly impressed Bob McCarley of Harvard Medical School?

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.

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

12. In the fifth paragraph, what does the word ‘it’ refer to?

A. an enzyme
B. new evidence
C. a catabolic state
D. enforced lack of sleep

13. What aspect of her findings surprised Chiara Cirelli?

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.
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 behavioral 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.

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 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.

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 recent study found children in foster care three times more likely
than others to be diagnosed with ADHD.

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’.

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 medication isn’t rare; it’s common. Just observe the many patients periodically seeking an
increased dosage 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 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 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 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 work needs to be done before we can settle the questions surrounding the
diagnosis and treatment of ADHD.

Text 2: Questions 15-22

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.

16. What does Dr Saul object to?

A. the suggestion that people need stimulants to cope with everyday life
B. the implication that everyone has some symptoms of ADHD
C. the grouping of imprecise symptoms into a mental disorder
D. the treatment for ADHD suggested by Dr Barkley

17. The writer regards the study of children in foster care as significant because it

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.

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.

20. In the fi fth paragraph, it is suggested that drug companies have

A. been overly aggressive in their marketing of ADHD medication.

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.
D. encouraged the APA to rush through changes to the criteria for diagnosing ADHD.

21. In the final paragraph, the word ‘trademark’ refers to

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.