Scenario 1 – Mrs Chan
Mrs Chan has been bought in by ambulance following a fall at home, where she fractured her hip. She believes she fell around 10pm last night, and was unable to get up to seek help. Her daughter found her still on the floor this morning at 6.00am and called the ambulance.

Mrs Chan’s past medical history includes:
• Urinary incontinence
• Osteoporosis
• Compression fractures to her spine due osteoporosis
• Removal of a Stage II melanoma in 2006
Regular medications:
• Fosamax
• Vitamin D
• Calcium
• Fentanyl patch
PRN endone

Question 4
When Mrs Chan is admitted to hospital, she is found to have mild hypothermia.

(a) Explain what hypothermia is and at least three factors that may have caused this in her case.
Hypothermia has been referred to as a condition characterised by the body losing more heat than what it produces often because of prolonged contact with cold. Patients develop this condition slowly, and body temperature falls below 35 degrees Celsius. Patients suffering from hypothermia will show signs of uncontrolled shivering, memory loss, depression, and poor judgment. If hypothermia advances, the patient develops an irregular heartbeat, and may lose conscience. At times, the patient can stop responding to painful stimuli. Severe hypothermia patients start showing signs similar to a dying person, for example, no response to painful stimuli and their pulse and respirations become extremely low. In addition, as the temperature of the body drops below 35 degrees Celsius, it becomes essential to keep assessing it. In case temperature falls below 35 degrees Celsius, a particular type of thermometer would be used having that not all are capable of registering a temperature below these degree Celsius (Schoenwald & Douglas, 2017).
The factors that may cause hypothermia in the case of Mrs. Chan include; inadequate clothing during the winter, getting cold on a wet floor because she was unable to move, tired and cold, elderly person reduction in muscle mass, possible hemorrhage, incontinence, and inshock.
There is a possibility that Mrs. Chan would have been going to the toilet when she had had a slip and fell on the floor, considering it was a cold night. Moreover, she might be wearing a night suit and hence lacked enough winter clothes to keep her warm during the incident. In addition, her past medical history shows urinary incontinence, so there is a chance she urinated on the floor. Thus following the slip, she could not get up and was forced to continue lying on the floor. As a result, she fractured her hip because she has a history of osteoporosis (TAFE Queensland, 2016).
(b) Define homeostasis and name the three components that make up any biological homeostatic control mechanism
Homeostasis has been defined as the process where the body maintains a steady internal environment to perform its functions and maintain equilibrium. For example, the body retains average body temperature. Three elements make up any biological homeostatic control mechanism where the first element is sensory receptors. If a change occurs in the normal function of the body, the sensory receptors will detect the changes in the environment and send bodies control mechanism signals, such as hot and cold environment outside the body. The second element is the control centre which receives information from the receptors and uses this information to analyse the situation and then decide appropriate responses. For example, the person will start sweating if the weather is hot or will begin shivering if it is cold. The final element is the effectors. Effectors are impulses sent from the control centre of the specific body organ to maintain stable body functions. Moreover, muscles and glands implement these responses (TAFE Queensland, 2016).
C) Describe at least four different changes that would occur in Mrs’s Chan’s body to regain temperature homeostasis.
Four dissimilar changes take place in the body of Mrs. Chan’s to regain temperature homeostasis the first being her body increasing the metabolic rate raising the production of heat. Secondly, she will experience increased vasoconstriction that means tightening of the blood vessels by small muscles of their walls. The third change will be a reduction in the heat loss and pushing of blood from the peripheral vascular bed to the core while the fourth and final change will be increased shivering of the body as a result of more production of heat (Schoenwald & Douglas, 2017).

Question 5

(a) The four major types of cellular adaptation are hypertrophy, hyperplasia, metaplasia and dysplasia. Briefly describe each of these types of cellular adaptation

Hypertrophy is the ability of cells to grow in size and widen. For example, when muscles size increases in bulk and tone the cells of tissues experience growth which is hypertrophy in response to fitness training and diet (Waugh & Grant, 2014). Hyperplasia happens when cells start to divide more rapidly in comparison to the previous situations and increases the size and number of organ tissues. For example, during pregnancy and breastfeeding, the size of the breast size increases in size and number of cells increases for the organ to grow. Similarly, in case of tumours, multiplying of cells means mitosis is uncontrolled, and new cells show abnormal characteristics (Waugh & Grant, 2014).
On the other hand, metaplasia is the abnormal potentially reversible replacement of one type of cell into another kind. In case of irritation and inflammation in response metaplasia happens. For example, metaphasis is reversible in adult cell type when epithelial cells are replaced by other cells. The adaptive nature of substitution of the cell may be sensitive to stress and will be better able to survive in the adverse environment (Humpath, 2018). Finally, dysplasia is a case where tumour cells may retain most of their features as their parent cell, but there is an increase in abnormal growth of cells. Consequently, there can be increased cell growth, which if not controlled the result would be enlarged tissues, malignant tumours or pre-cancerous cells (Humpath, 2018).

(b) Define atrophy
Atrophy can be defined as the condition when the size of a cell or the number of cells decreases. For instance, when cells size of muscles decreases, the mass of the muscle also decreases. If limbs are in a plaster cast in case of a fracture because of lack of nutrition or oxygen supply the results can be atrophy (Waugh & Grant, 2014).
(c) What does the term ‘surgical insult’ mean?
Surgical insult refers to how the body reacts after a surgery has been performed. Surgical insult has the capability of influencing inflammatory response as well as hormones that affect the various systems of the body and not only the areas which was operated (TAFE Queensland, 2016).
Question 6
Part of the ENs role is to assist in referring clients care to the appropriate people within a multi-disciplinary team
(a) List six (6) different professions that may be part of a multi-disciplinary team.
Enrolled nurses are part of a multidisciplinary team that also consists of medical, nursing, allied health, and support staff. All these skilled professionals work together as one multidisciplinary team. Some of the different professionals who may be part of the team include doctors, registered nurse, social worker, physiotherapist, administration staff and a specialist (TAFE Queensland, 2016).

(b) Which part of the team has the role of interpreting test results in order to formulate a diagnosis?
The team with the responsibility of interpreting the outcome of the test before formulation of diagnosis include medical practitioners as well as professionals such as doctors and the team registrar (TAFE Queensland, 2016).
(c) Why does the EN need to know the purpose of blood collection?
The enrolled nurse is required to have knowledge and understand the rationale of blood collection to educate the patient whose blood sample is taken for the test. Additionally, the enrolled nurse should inquire from the patient about fasting. The reason for this is that some samples require fasting for a period before being collected for the test. If the patient is given appropriate information about the blood test, they will become confident, less fearful and more willing to be part of the test. Therefore, for nurses, they have a mandatory obligation to inform and educate patients and patients will trust the test (TAFE Queensland, 2016).

(d) Can an EN disclose pathology results to their client? Give a reason for your answer.
The answer to the question is negative in that the enrolled nurse cannot reveal pathology results to the patient. Medical practitioner’s such as doctors and specialists have a role as to translate these tests results and define an analysis.In any case, enrolled nurses just have to understand the reason for gathering blood test so that patients can be given appropriate information and education about the test. In particular cases, like bedside test that is recorded by healthcare workers enrolled nurses can identify common outcomes and report similarly. Thus, if the glucose test report is not appropriate, they are allowed to inform (TAFE Queensland, 2016).

Scenario 2 – Mr Marconi
Mr Marconi is a 76-year old man who has hypertension, hyperlipidaemia and congestive heart failure. He is brought in to the Emergency department at 06:00. On arrival, Mr Marconi states that he has chest pain when breathing in, he is coughing up yellow phlegm and he feels exhausted. His left arm has a shallow wound that Mr Marconi said he got while weeding his garden two days earlier.

His vital signs include:
• Respiratory Rate: 28 bpm (shallow with pain on inspiration)
• SaPO2: 91% (2L O2)
• Blood Pressure: 105/70 mmHg
• Pulse Rate: 105 bpm
• Temperature: 38.9 degrees C
• BGL: 4.5mmol
• Weight: 78 kg
• Height: 174 cm
His current medications include Atenolol, Ramipril and Lipitor.
He has no known allergies.
Question 7
Describe the process of coronary artery atheroma formation – include the following in your answer:
(a) Describe the steps of atheroma formation.
Formation of artheroma follows six unique steps. The first step is the damaging of the endothelium. The chemicals that are present in the blood system damages the tunica intima. For instance, cigarette smoking is a contributing factor to hypertension because of bacterial and viral infections. Moreover, this injury to endothelium causes inflammation in response to repair the damage to arteries walls. The second step is the accumulation of a lipid in the tunica intima. As a result, the injured endothelial cells cause the release of chemical agents and growth factors.
Moreover, low-density lipoproteins deliver cholesterol to the tissue cells while on the other hand, low-density lipoproteins transport cholesterol to the tissue cells which later oxidize in the inflammatory environment and also damages all the cells around it. The third step is the attraction of macrophages which forms the foam cells. Eventually, the attracted macrophages get loaded with low-density lipoproteins which than transforms into foam cells. The next step is the foam cells forming a fatty streak that become the first noticeable signs of a person developing an atheroma. In the fifth step, smooth muscle cells proliferate while at the same time there is formation of the fibrous cap. A smooth muscle fibre (tunica media) consists of layers where the artery grow which turns the fatty streak into a plague. Moreover, this plague blocks parts of the vessel. Furthermore, there is a restriction of movement and flexibility of the artery. The blockage results in a reduction of the rate of blood flow to the heart. Lesser blood flow means the heart is supplied with less oxygen and this can lead to heart diseases, attacks, and angina. Finally, the plague becomes unstable having that when the epidemic continues to grow, cells at the centre starts to die. Calcium begins to deposit and the collagen fibre production slowly declines. Moreover, this plague may rupture, and this will eventually cause atheroma formation (Anatomy & Physiology, 2018).
(b) Name three factors that trigger endothelial inflammation.
A number of factors trigger endothelial inflammation among them being dyslipidemia, diabetes, family history, cigarette smoking, sedentary lifestyle, obesity, hypertension, psychological factors and age (Thanassoulis & Afshar, 2017).

(c) How do high and low density lipoproteins contribute to atheroma formation?
Low-density Lipoproteins(LDL) is considered to be “bad” cholesterol. LDL is a high-level type of cholesterol which builds upon the walls of the blood vessels and eventually narrows the passageways. Consequently, the blood is forced to pass through the vessels through difficulty. Clots are formed from ruptured blood vessels which are the cause of intraarterial walls fat deposits and fibres, and these clots obstruct in the narrowed spaces preventing the blood from passing. Moreover, there are high chances that a person gets a heart attack or stroke. LDL contributes to atheroma formation.
High-density lipoproteins(HDL) is identified as the “good” cholesterol and assists in removing of any form of ‘bad’ cholesterol from bloodstreams. Additionally, HDL assists in the reduction of excess cholesterol present in the blood by taking it to the liver which breaks the cholesterol down removing it from the human body. People who have higher levels of HDL have fewer chances of heart disease like heart attacks, strokes, and angina. Moreover, it prevents LDL forming atheroma formation and clots. HDL assists in keeping the blood vessels healthy in general (Mayo Foundation for Medical Education and Research, 2016).
(d) What is the role of macrophages in relation to atheroma formation?
White cells called monocytes in the subendothelium can be described as connective tissue that is between the endothelium and inner elastic membrane in the intima artery walls that transform into macrophages. Low-density lipoproteins are lipids in the blood, ingested and accumulated by macrophages going through oxidization in artery walls. These oxidized lipids and macrophages become lipid-filled form cells. As a result, the accumulation of cells contributes to lipid storage and atherosclerotic plague growth which is called atheroma formation. Macrophages engulf pathogens and damaged cells after which macrophages release proinflammatory factors called cytokine chemical to maintain microenvironment in the vessels. These help the process of repairing of any damaged vessels and stimulate the growth of new macrophages.
Macrophages have numerous roles in the human body. First, they are responsible for the healing of lesions in the blood vessels, meaning they come into action when there is a tear or damage to the blood vessels. Secondly, they provide services like engulfing pathogens and damaged cells. Another function of the macrophages is releasing of cytokine chemical that is a proinflammatory factor. They are also responsible for stabilization of the plague in the blood vessels that helps in lipid accumulation. In addition, macrophages can be the reason of unstable plague that can be the start of a coronary atheroma formation in the blood vessel. Moreover, when macrophages are healing and repairing the coronary artery atheroma, they may remodel the blood vessels by promoting the growth of smooth muscle cells that is surrounded by connective tissues as well as Intra and extracellular lipids. There is also the possibility of developing uneven vessels and form scars that may not level up with the rest of the skin. Finally, macrophages can stimulate thrombosis in case of plaque ruptures, and plague content gets exposed to circulating blood (Thanassoulis & Afshar, 2017).
(e) The patient is taking Atenolol and Ramipril. Describe in simple terms (that a patient could understand) how these two medications work in treating ischaemic heart disease.
Atenolol helps the heart to thump more quickly. These medication treats the hearts abnormal rhythms and also minimises the contraction force of the heart muscle and lowers blood pressure. Atenolol reduces the hearts muscles works and the need of muscle for oxygen. Ischaemic heart diseases usually occur when oxygen demand exceeds the supply of the heart muscles. Atenolol is used in treating heart diseases like angina (Atenolol, 2013). On the other hand, ramipril is used in the treatment of high blood pressure. Through it, the blood vessels are relaxed, helping the blood flow more smoothly. The medication is used in the prevention of heart attacks and strokes (Ramipril, 2013).
Question 8
You are asked to clean the wound on the patient’s arm.

(a) Explain the structure and the function of the skin and the problems associated with a break in the skin such as this wound.
Skin is the largest organ of the body with a total area of approximately 20 square feet making a waterproof and protective layer which works as an airtight and flexible barrier between the internal organs and microorganisms outside and also prevents the body from getting dehydrated. These functions help to keep internal body environment stable, and even maintain equilibrium (ACD, 2018).
The skin has three layers; epidermis, dermis, and hypodermis or subcutaneous layer. The epidermis is the outer most layer and its thickness varies depending on the location on the body. Epidermis tends to be thicker on the soles and palms. Furthermore, the layer is flexible and resists any mechanical injury. Eyelids have thin skin which gives maximum movement. Epidermis helps to in the prevention of water loss and body fluids. Additionally, it helps to resist mechanical and chemical abrasion to internal organs and offers protection against bacteria, viruses, and parasite infection. The pigment in the epidermis is critical in preventing the skin from the ultraviolet radiation of the sun. Moreover, also helps in the production of vitamin D by sunlight which in turn keeps bones healthy. The hair follicles, sweat gland which works as an excretory organ for excreting water salt and urea, sebaceous(oil)and apocrine glands develop from the epidermis cell, and the more in-depth parts extend into the dermis. Small ducts which are open on the surface of the epidermis are called glands. Nails grow from hair follicles. Hair follicles are found everywhere on the skin besides the palms and soles. Nails are supposed to be plater of a specific type which is made up of keratin which develops from the epidermis and small bones at the end of the fingers and toes (ACD, 2018).
Three types of cells in the epidermis are keratinocytes (skin cells), langerhans (immune cells), elanocytes (pigment cells) and the epidermis which is mainly made up of keratinocytes. The cells develop from the bottom moving upwards the base layer in a period estimated to be of four weeks. These cells move towards the upper surface which is known as the stratum corneum where shedding happens. The body’s immune response to foreign infections and materials is made possible by the presence of Langerhans cells a special type of immune cells. On the other hand, every human being has the same number of melanocytes cells which are responsible for production of pigment. Furthermore, the human skin colour is the way it is because of the melanocytes where a dark skin means that it is present. The epidermis cells that are protected by the melanin pigment prevents the skin from sun damage. Therefore, the sun easily damages lighter skin people because melanocytes produce less melanin pigment. Finally, the Dermo-Epidermal Junction is considered a complex region, which is where the dermis and epidermis meet each other through specialized cells and molecules, and it contains the basement membrane (ACD, 2018).
The dermis is the second layer that is underneath the epidermis, and has been estimated to be twenty to thirty times thicker. The dermis is made up of collagen and elastin proteins organized in fibres of different sizes and properties. A complex gel surrounds these fibres, and it is called the extracellular matrix. The dermis has two layers papillary layer and the reticular layer where the papillary is a superficial layer with a projection known as dermal papillae. The layer has touch receptors such as pain receptors and capillary loops. On the other hand, the reticular is the deeper and thicker layer of the dermis and occupies the largest part. Blood, lymphatic vessels, nerves, roots of hair follicles and sweat glands are present in this area of the dermis (ACD, 2018).
Subcutaneous layer is underneath dermis, and consists of collagen fibres and fat cells called adipocytes where the thin layer protects the body from any external trauma and fat insulates the body and helps regulate temperature. Considering the layer is made up of fat, it stores and provides energy when required by the body. In the subcutaneous layer blood and lymphatic vessels pass through subcutis. The thickness of the layer may vary depending on the location of the body parts which means it differs from one person to person (ACD, 2018).
The following problems have been associated with a break on the body’s skin such as a wound. First, the wound could be infected and may spread if not treated. Infection can turn the skin around red, swollen and sore. Moreover, the disease can spread to deep tissues, and layers of the skin and spreading of the infection are called cellulitis. Secondly, sometimes a disease can spread through the blood in the patient system. The patient can get a fever, and advanced stage of this infection is called sepsis. Thirdly, the wound may not heal until the infection is treated. Additionally, the injury can start getting lumps of pus called an abscess. Furthermore, infections which are called flesh-eating bug medical term necrotising fasciitis which affects vast skin areas which can get very painful and damaged. Finally, the wound can get other infections like impetigo or tetanus (Harding, 2018).
(b) You notice that the patient’s skin appears thin and like ‘tissue paper.’ Explain what may have caused this.

Normally, various factors might cause the skin to emerge like thin tissue where the first instance would be when a person starts to become old because of aging, the skin tends to lose its elasticity and become dry. Secondly, certain genetic conditions can cause person’s skin to appear like thin tissue. Thirdly, staying in the sun for long hours can cause skin damage. Also, some medication older people can have side effects like steroids. Finally, medical conditions can change the appearance of the skin (TAFE Queensland, 2016).
Question 9
The patient wears reading glasses. Explain degenerative changes that occur in the eye as we age and how this may have resulted Mr Marconi’s need to wear glasses.
Degenerative changes take place in an individual cells or whole organ in time because of aging. Moreover, ageing tends to be the reason which changes in function and appearance. Degenerative changes occur in all organs systems including vision. For example, presbyopia and cataracts are common in old age (TAFE Queensland, 2016). In old age, the lens tends to lose its elasticity and becomes firm which leads to a loss of accommodation. As a result, there is prevention from focusing of light on the retina of eyes and causes blurry vision. Nevertheless, correction of this degeneration change is attained through the use of glasses with the help of convex lenses for in front of vision for instance, reading (Waugh & Grant, 2014).

Scenario 3 – Mrs Thompson
Sarah Thompson is a 65 year old woman who presents to her GP clinic for an annual check up. She was diagnosed with Type II Diabetes Mellitus (T2DM) in 2009:

Weight: 95kg
Height: 164cm
BMI 36

Mrs Thompson also has hyperlipidaemia and hypertension, and she is taking Metoprolol and Rosuvastatin daily.
Question 10
Discuss Type 2 diabetes – include the following in your answer:
In Type 2 diabetes patients pancreases can produce insulin however, body is unable to convert glucose into energy (TAFE Queensland, 2016).

(a) What body systems and/or organs can be affected by T2DM?
The cardiovascular, circulatory, nervous, visual and urinary systems are most commonly affected by type 2 diabetes mellitus which is caused by chronically high blood sugars as the body is unable to convert glucose into energy (Mikesh, 2010). Moreover, organs affected by T2DM include the kidney, blood vessels, feet (nerves), eyes, skin, and heart (Livestrong, 2018).
(b) Name five risk factors for developing T2DM
Risk factors for rising T2DM are weight, age, race, hereditary, inactivity, Gestational diabetes, hypertension, and medication. Being overweight and obese will increase the risk of being overweight. It is the primary reason for being overweight. In terms of ageo lder people are prone to T2DM (Falck, 2018). Additionally, people from some countries and regions tend to be more at risk of diabetes than the other countries or regions like Asia, India, Pacific Islanders, Indigenous Australians. Genetic history of the person may play a role in people inheriting T2DM. If family members of a person have diabetes, they also tend to have it (Lazear & Alford, 2015). Nowadays many children have diabetes as they do not have an active lifestyle. Some women may be diagnosed with diabetes during pregnancy, which is a temporary condition during which pregnancy as the hormones in the placenta blocks insulin.The Long-term condition of high blood pressure in the arteries can be one of the risk factors for developing type 2 diabetes. Finally, various medications like for depression can inhibit the glucose being converted into energy. And patients who take them are at risk of developing type 2 diabetes (Lazear & Alford, 2015).
(c) Describe appropriate treatment for a patient such as Mrs. Thompson who has T2DM
A suitable balanced diet and metformin tablets which have to be taken 1-3 times a day as per the Australian Dietary Guidelines could control proper treatment of patients having T2DM like Mrs. Thompson. Additionally, she should eat a healthy variety of nutritious foods. Mrs. Thompson should be physically active like go for a brisk walk for at least 30 minutes almost every day. Control and maintain healthy body weight. Her body is making insulin. However, the body builds resistance and is unable to convert glucose to produce energy (TAFE Queensland, 2016).
(d) Which part of the cell makes ATP (adenosine triphosphate) needed for cellular energy
In the human body cell, adenosine triphosphate is a requirement for cellular energy production in mitochondria and consequently, mitochondria are called the powerhouse of the cell because of their function (TAFE Queensland, 2016).

(e) What is required to ensure a cell remains healthy?
Every body cell including the cellular process requires energy and oxygen to perform its functions and at the same time ensure a cell remains healthy (TAFE Queensland, 2016).
Question 11
Define hyperlipidaemia and explain the associated risks and causes of this condition. In your answer identify the roles of high density lipoprotein (HDL), low density lipoprotein (LDL) and triglycerides.
Hyperlipidaemia can be defined as a state where blood has elevated levels of cholesterol. The following are the risk and causes linked to hyperlipidaemia (University of California, n.d.). First, there is an amplified risk of cardiovascular disease and stroke. Consuming an improper diet leads to high saturated fats and cholesterol levels in the blood. In addition, there is increase in weight which will lead to obesity. Having a BMI of 30 or higher puts a person at risk having too much cholesterol in the body. Being deficient of exercise and inactivity will increase the bad LDL cholesterol in the body and decrease the good HDL cholesterol in the body. Medical conditions like diabetes, hypothyroidism, kidney disease and liver disease may develop, and they increase the production of LDL and lower HDL. It will also damage high sugar in the body can destroy the walls of arteries. Increased consumption of alcohol and smoking will also put the person at risk of accumulating fat in the body. Some medications can cause increased levels of cholesterol in the blood. Family history also occurs to be a contributing factor. Finally, it can be genetically passed to affected person and then on to next generation.
Hyperlipidaemia is a cholesterol which is waxy whitish substance and is a vital part of our health (University of California, n.d). Cholesterol does not have any energy valve however, it helps to serve as a building block for vitamin D, digestive bile, many sex hormones and it also helps maintain the outer layer of body cells. Animal food sources in our daily diet consumed, is an excellent source of cholesterol but the body is has the ability to create a particular type of cholesterol. Extra cholesterol not used by the body effects arteries over time negatively. Moreover, when not controlled it can cause hyperlipidaemia. Cholesterol starts to collect plague in the arteries walls and just like rusted pipes, arteries which with dangerous amount of clogged plague make it difficult for blood to pass through. In turn, it makes the oxygen and carbon dioxide to pass through the arteries which result in heart attacks and strokes (University of California, n.d.).
LDL stands for low-density lipoprotein normally identified as “bad” cholesterol as it consists of all the fats which forms plague that clogs the arteries. The most favourable LDL level is < 130mg/dL or less than 100/dL in individuals who face high risks. On the other hand, HDL is high-density lipoprotein is called “good’ cholesterol and it is the cholesterol which prevent LDL cholesterol from building up in the arteries. Optimal HDL level is > 40 mg/dL in men and >50 mg/dL in women(University of California, n.d.). Finally, triglycerides is a form of fat which is found in blood, and is the primary constituent of natural fats and oil in our daily diet. The food individuals eat is converted into calories and rest which does not need to be used right away as triglycerides. Moreover, triglycerides are stored in the body in the form of fat cells. Later these triglycerides may be released by hormones between meals. Optimal level is >100 mg/dL to <150 mg.dL is the upper limit (Mayo Clinic, 2015). Scenario 4 – Miss Walker Miss Walker is a 46-year-old female who preted to the emergency department with shortness of breath which has got progressively worse over the last two days. She has no other significant past medical history. RR: 26 SpO2: 93%. The doctor orders a chest X-ray that shows consolidation of fluid on his right lower lung. The doctor diagnoses right lower lobe pneumonia. Question 12 Relate the diagnosis of pneumonia to two stages of respiration - external respiration and gas transport. (a) Describe what occurs during normal external respiration. According to Porrit, (2017), various occurrences happen in normal external respiration first being an exchange of gases between the pulmonary capillaries and the atmosphere. Exchange of gas happens in the alveoli at a time when there absorption of the hemoglobin into the body. In addition, during the same time the carbon dioxide that is in the red blood cells is removed. Among the critical things to note is that all this happens in the lungs. While oxygen in the body moves from the alveoli which is highly concentrated to the blood capillaries with low concentration, the carbon dioxide moves from the blood capillaries higher concentration to the alveolar lowly concentrated area. The pulmonary valves are tasked with the responsibility of collecting blood from the capillaries, as it is rich in oxygen and uniting to create two pulmonary veins that enter the heart’s left atrium from each of the human being’s lung (Porritt,2017). Consequently, rapidly, the oxygen diffuses from the alveoli entering the blood system while the carbon dioxide goes to the direction opposite. TAFE Queensland (2016), states that respiratory membrane that is in the alveoli is slim presenting an enormous surface area for efficient and easy exchange of gases. (b) Describe what occurs during normal respiratory gas transport. Discuss how O2 and CO2 are transported in the blood Normal respiratory gas transfer refers to the process of transporting carbon dioxide and oxygen into the blood system. According to TAFE Queensland (2016), an estimated 1.5% of oxygen available is dissolved into plasma nevertheless, the remaining 98.5% oxygen carries on as haemoglobin which is considered to be four molecules bounded together on each single particle. The amount of BPG, temperature, PCO2, and blood pH in the body has the capability of influencing the saturation of the haemoglobin during any point in time. Important to note is that haemoglobin lacks an affinity for oxygen which means that the unloading and loading of oxygen is efficient. The lungs secret nitric oxide (NO) which is also released by the vascular endothelial cells and is carried by the haemoglobin to the body tissues. Here, the NO enhances the transfer of oxygen and its vasodilatation. In the plasma, the amount of carbon dioxide, which is dissolved, is approximately 7-10%. At times 20% is carried as haemoglobin bound to globins but 70% of the carbon dioxide is transferred as a bicarbonate assisting th body to maintain balance in the blood ph (TAFE Queensland, 2016). (c) Differentiate between pulmonary ventilation, internal respiration and cellular respiration. Pulmonary ventilation is the mechanical breathing process where pressure and volume changes during the thoracic activity causing the flow of gas from and out of the lungs. Medical terms given to these activity are “expiration” and “Inspiration” sometimes called “exhalation” and “inhalation” (TAFE Queensland, 2016). During inhalation, the lungs stretch and fills the enlarged thorax where the air is pushed into the respiratory passage. On the other hand, during exhalation, the elastic tissues of lungs recoil and force the air out of the respiratory passage (Porritt,2017). On the other hand, Internal Respiration could be described as the exchange in respiratory gases such as carbon dioxide and oxygen occurring between the tissue cell and the systemic blood. While the oxygen in the body unbinds from the hemoglobin diffusing diagonally the blood vessel membrane into the tissues surrounding the carbon dioxide is transported in reverse. Thus, oxygen and carbon dioxide travels in an opposite direction. During the process of respiration, the inhaled oxygen moves into the blood across the alveoli through the pulmonary capillaries. Consequently, oxygen is loaded into the hemoglobin while the remaining dissolves in the plasma (TAFE Queensland, 2016). The oxygen that is in the blood present in the capillaries is taken for purposes of being used by the body organs and tissues. Cells produce carbon dioxide as a waste product after the oxygen has been used and later transported into the blood system through the veins, returning to the lungs. There are three forms in which carbon dioxide is transported including being dissolved into the plasma, being attached to the hemoglobin, and carried as bicarbonate. Later, the carbon dioxide moves to the lungs from the blood that is across the alveoli. Finally, it is breathed out which completes the cycle of oxygen inhaling and carbon dioxide exhaling. (TAFE Queensland, 2016). Finally, cellular respiration occurs in systemic capillaries (TAFE Queensland, 2016). Here, gases from the interstitial tissues are diffused into the body cells for purposes of metabolism. During the metabolism of nutrients in the human body, the cells produce carbon dioxide and uses oxygen. The carbon dioxide is diffused from the cells that are present in the interstitial tissue. At any point that the body is producing energy, this chemical reaction occurs (Porritt, 2017). (d) Briefly explain what respiratory acidosis and respiratory alkalosis are: To ensure normal functioning of the human body, there is need to achieve a balance between the base and acids. Balance between the base and acid in the body is referred to as regulation of the pH. All the chemical reaction and processes that happen in the body requires a particular pH. Moreover, changes in pH will interfere with reactions in the body. Acid emanates when a substance splits into H + and an anion such as Cl – like HCl → H + + Cl −. An acid splits into a hydrogen ion (H + ) during a chemical reaction. Base: A substance that will combine with H + during a chemical reaction and removes H + from a solution like OH − + H + → H 2 O. A base is an H + acceptor. The hydroxyl ion (OH − ), for example, combines with H + to form water abbrevited as H 2 O. On the other hand, pH is a unit of measurement which will indicate the number the number of H + in solution. If the number of H + increases in solution and pH will decrease and vice versa. The average plasma pH ranges from 7.35 to 7.45. Ideally, the plasma should have a pH of not more than 7.35 where being in this state is known as acidosis. However, a plasma pH of more than 7.45 is called the alkalosis (Herlihy, 2014). In a similar manner, after the carbon dioxide has left the body cells, it mixes with water forming the carbonic acid (H2CO3). The presence of carbonic acid in the human body lowers the blood’s pH that later makes it to be more acidic. In normal circumstances, the body’s respiratory system functions to maintain the respiratory rate that keeps the carbon dioxide within the array of 35-45 mmHg in the blood. As a result, the pH undergoes some changes because the carbon dioxide happens to be controlled well. If carbon dioxide levels increase, the carbonic acid level increases, lowering the pH of the blood. If carbon dioxide levels decrease, the reverse will occur, and it will raise the pH. In cases when there is a respiratory condition such as emphysema or asthma, the removal of carbon dioxide in the body experiences reduction. Thus, the CO2 remains in the system of the blood while the pH increases its acidic concentration, pH<7.4. Considering the increase in acidity is caused by the presence of high carbon dioxide, the result is referred to as respiratory acidosis. Additionally, a condition which happens to increase the respiratory rate such as lower production of carbon dioxide (hypothermia) or panic attacks, reduces the CO2 level in the blood causing respiratory alkalosis pH>7.4. When an individual experiences hypothermia, respiratory rate lowers maintaining a normal or average pH (TAFE Queensland, 2016).

Question 13
Describe the steps involved in homeostasis of respiratory rate – include the following in your answer (min 200 words):
(a) Name two (2) respiratory gases detected in the blood?
The two respiratory gases that are identified in blood are oxygen which humans inhale to produce energy (digestion) and carbon dioxide, which is exhaled as a metabolic waste item (Porritt, 2017).

(b) Where is the respiratory control centre located? What is the stimulus that causes the respiratory control centre to increase respiratory rate?
Breathing is controlled through three respiratory centres specifically, the apneustic centre in the pons, the medullary centre, located in the medulla oblongata, and the pneumotaxic centre in the upper pons of the brainstem. The function of the centres is receiving stimuli from the sensory cells and at times they also provide for each other In addition to this, these centres are responsbile for controlling the rate of respiration, depth of ventilation and the ryhthm (Porritt, 2017).
(c) Why would the patient have an increased respiratory rate if they are suffering from pneumonia? You need to explain the physiology behind why having pneumonia causes increased respiratory rate
Pneumonia is described as an infection which affects the lower airway and occurs in the presence of microorganisms. The common symptoms associated with pneumonia include inflammation and mucous plugging. In addition, these symptoms impacts on the gas exchange during external expiration (TAFE Queensland, 2016). The presence of a dysfunction in a human lungs has a direct impact on the thickness of the alveolar capillary membrane. As a result, the surface area is reduced affecting the respiratory functions within the human body. In a condition of pneumonia, airways are blocked and obstructed because of disease’s symptoms. Moreover, all this reduces the diffusion of oxygen and CO2 because of which lungs have to work more and respiratory rate increases (Porritt, 2017).

(d) How does administration of supplementary oxygen help to maintain homeostasis of respiration?

The respiratory system maintains homeostasis in two methods that include regulation of blood pH and gas exchange. Gas exchange occurs through the lungs by elimination of a carbon dioxide. CO2 is a waste product that is produced by cellular respiration. The question now remains how administration of supplementary oxygen helps to maintain homeostasis of respiration. What happens is that as the CO2 exits from the human body, through the lungs, the oxygen that is needed for cellular respiration enters. In people who are healthy, increase in CO2 causes increased drive to breath; however, people with chronic disease such as obstructive pulmonary their response has been blunted which leaves low levels of oxygen as the primary stimulus of the respiration. Therefore, if the body lacks the supplementary oxygen, the functioning of the brain is affected in addition to developing problems associated with poor sense of judgment. In the occurrence, the body inhales plenty of the supplementary oxygen; it is ‘processed’ by alveoli before being delivered to the cells after absorption in the blood stream. If the blood in the body lacks enough oxygen for sufficient respiration, lungs adapt with an aim of bringing more oxygen. For instance, when one goes for a run, the work muscles do increases requiring more energy. Consequently, respiration increases making the body need extra oxygen to meet the demand. These developments explain the quicker and heavy breathing during exercises. As a result, homeostasis is achieved (Fuhrman, 2011).

(e) What impact would the administration of supplementary O2 have on the patient’s respiratory rate? What impact would the administration of supplementary O2 have on the patient’s SpO2?
The respiratory rate in a patient decreases because of administration of supplementary oxygen (Scully, 2017). Giving supplemental oxygen to a patient leads to a reduction in the stimulus to breath which eventually causes respiration to slow in what is called hypoventilation sometimes referred to as respiratory depression and at the same time allows CO2 to be accumulated in the body. The purpose of administering supplementary oxygen is to achieve near or normal oxygen saturation. Moreover, the type or amount of supplementary oxygen administered depends on the condition under treatment. Either high or low concentrations can cause harm. Therefore, in general, administration of supplementary O2 increases the patient’s SpO2 (Beasley, et al., 2015).

Question 14
Later in your shift, you find the patient crying. She tells you that she has been crying a lot lately and feeling sad since her husband asked her for a divorce. Explain psychological health as it relates to the patient and who you could refer them to.
Psychological well being is an essential part of human life as all mental emotional, social, behavioral and spiritual part of the life of a person has affected their psychological health. Mental health consolidates of psychological factors like stress, sadness, and employment control.As per some studies, all these factors are linked to psychological health and also to some coronary illnesses. A person who is mentally fit has the capacity and ability to handle stressful situations. Also, the person can acknowledge their mistakes and learn from them and will not get mixed up and point fingers at others for something that has happened in their life. They will know whom to ask for help and where to look for it. For example, they may call beyond blue to speak with a counselor for assistance. As an alternative, they may seek medical help by making an appointment with a General Practitioner, or speak to family or close friend, or decide to go for holidays to rest, socialize and organize their life again.
Depression and anxiety is a significant mental health issue in Australia, and it happens to affect 1 in 20 Australians each year.Also, it can affect anyone each year which makes about six hundred thousand people have severe mental disorders. I would refer the female patient who is crying a lot and is mostly depressed about her divorce to Social Worker, Family, and friends, General Practitioner, Helpline numbers, Psychologist, Councillors, Psycatricist, and a Psychotherapist. Other professionals and techniques which would be of assistance include Support groups, Reach support group( Black Dog Support Group), E-mental health tools, Health Websites, Emergency help, Mental health services, and Community health services. I would also recommend seeking assistance from an Occupational therapist, Mental health nurses, and the Aboriginal and Torres Strait health workers (TAFE Queensland, 2016).

Question 15
(a) Explain how you would prepare for a urinalysis test?
Urinalysis is a ward routine. Urinalysis helps in determining the health status of a patient. Many medical conditions can be detected by performing urinalysis such as any fluid volume manifest in the urine. Urinalysis is completed on patient’s admission preoperatively. If urine of patient is offensive and nurse suspects an infection there is the possibility of some medical conditions.
There are five significant steps that a healthcare professional can prepare for a urinalysis test. The first step is ensuring that the fresh specimen has to be always collected for this analysis. Secondly, the practitioner should make sure the collection receptacle is clean to prevent contamination which may even alter the test results.Thirdly, sterile gloves have to be used when the test is being done. Consequently, the urine is first observed and then tested using the test strip or reagent strip provided by the facility. These strips and what they check may provide mary because of different manufacturers. However, critical points listed are standard inclusions. Finally, the nurse will have to keep a piece of blank paper and pen handy to write the results which may later be recorded on the patient’s chart.
Characteristics of urine redetermined by observing specimen. Like observing amount, color (lemon, amber, bloodstained) clarity (clear or cloudy) and odor.
The reagent strip or test strip is used to test than other properties and substances. Check the reagent strip provided by the facility and also read the manufacturer’s instructions. Remove one secure strip rest by recapping tightly. The piece is immersed in urine in last test area and removed. Blot the strip on some paper towel and use a watch to note the time when the strip was dipped. Now nurse needs to hold the test strip close to the container and results in the guide without touching to avoid any contamination of the bottle. Use the guide on the bottle and check test area and their reaction time is reached. Usually, the result is negative besides the ph and SG as other components should not be there in the urine of a healthy person.
Specific gravity(SG) in the concentration level of the urine compared with that of an equal volume of distilled water. Ph is used to determine the acidity and alkalinity of the urine. All urine is tested for these readings. Any abnormalities are an indication of the health status of the patient.
Presence of glucose, ketones bodies, bilirubin, blood, nitrite, protein, leukocytes, and various other substances are abnormalities. The findings show some medical problems like kidney functions, urinary tract infection or diabetes. Moreover, any abnormalities have to be reported.
Note all the characteristics of urine like SG, ph and other abnormal test results on the patient’s nursing care plan, and their observation and response chart, including other documents (Tollefson, Watson, Jelly & Tambree, 2016).

(b) You assess the results of a urine dipstick test – list two (2) signs would you expect if a UTI was present?
Urine is referred to sterile body fluid any white cells present or bacteria in the urine is abnormal and indicates UTI. Bacterial counts of 10 5 colony-forming units per milliliter (CFU/mL) or higher often is an indication of a clinically major UTI. Nonetheless, counts that are as low as 10 2 to 10 3 CFU/mL in an individual with signs shows the possibility of UTI.
The few visual signs which can be commonly noticed by a nurse during dip stick test are abnormally cloudy urine, presence of blood in the urine (hematuria), and a foul and strong urine odour.
If the stick turns purple for leukocytes that indicates positive for infections in kidneys and UTI and if it turn light orange or cream on the chromatic scale means positive for UTI and reduction of nitrates to nitrites by gram negative bacteria (Czarapata & Bonner, 2015).

(c) What symptoms could the patient be experiencing if she has a UTI?
If Mrs. Ngyen is diagnosed with urinary tract infection, some of the symptoms she could be experiencing include; difficulty in starting to urinate, time delay between starting to urinate and to start to urinate, slow and thin urinary stream, burning and painful sensation during urination, no continuous urination, and after finishing to urinate completely, the patient still loses some urine. Other common symptoms are inability to urinate and an empty bladder, more than eight times the urinary frequency in a 24 hours period and about 200 ml each time, the sudden urgent urge to urinate, leakage and urine loss, and during night patient will have to get up 2-3 times to urinate. In addition, Mrs. Ngyen might experience leakage during the sleeping time, which disturbs patients rest time, urine may also contain blood cells and will appear cloudy, person will have fever, be stingy and also supera pubic pain (TAFE Queensland, 2016).

(d) A urine test is then ordered for culture and sensitivity. Describe what each of these tests are evaluating and how the results relate to medication prescription.
Uurine culture refers to testing either bacteria or germs that might be present in urine. Urine culture test is performed in case of complicated urinary tract infection persistent bacteria and in case of as frequently as 2 to 3 times per year recurring urinary tract infection.
Sensitivity: Urine culture can sometimes be accompanied by sensitivity testing for purposes of examining if the bacteria are sensitive to antibiotic drugs.
The findings help healthcare professionals in selecting the most appropriate antibiotic drug that will have the capability to kill bacteria responsible for urinary tract infection in the human body. Once a urinary tract infection is diagnosed antibacterial, therapy can be given. An antibiotic decided by a Doctor on the bases of the results of sensitivity test. Cystitis that is not complicated can be treated in the short-term use of antibiotics normally between one and three days. However, in case of complicated urinary tract infection, long-term treatment is given lasting 7 to 14 days or longer (Czarapata & Bonner, 2015).

(e) Explain how the patient’s age could impact the urinary system?
The age of the patient could affect the urinary system severally. The old person has bladder control problems such as leakage or difficulties when trying to hold urine which is called urinary incontinence. Sometimes an old person is not able to empty their bladder which is a problem related to urinary retention. An older person gets bladder and urinary tract infection quickly. Finally, the older person also gets chronic kidney disease in which slowly kidney losses functions over time (MedlinePlus, 2018).
The human kidney often has a substantial functional reserve meaning that if an individual loses one, no problems are caused. Thus, losing a single kidney does not make an individual unhealthy. When people age, the number of nephrons reduces, the renal tubules becomes less effective, the rate of glomerular filtration declines, and the kidneys ability to concentrate on urine become less. When these changes occur, older adults find themselves exposed to becoming sensitive to alterations in the balance of fluid. As a result, problems which are related to fluid dehydration and overload become more common. In addition, the use of drugs to eliminate the problems is less efficient as the declining function of the kidney leads to toxicity and accumulation. The capability of inhibiting contraction of the destrusor muscle reduces and this might result in emergency need for passing urine as well as frequency in urinary. Additionally, as age increases, nocturia becomes more common. In older adults, incontinence is prevalent where 15% of women are affected while 10% of men aged 65 and above face the risk of being diagnosed.

Question 16
(a) List five (5) oral health diseases
According to TAFE Queensland (2016) oral health diseases include; dental cavities, periodontal gum disease, oro- dental trauma, oral cancer, and cleft lip and palate.

(b) What is the term used to describe people with teeth and without teeth

A term describing individuals with teeth are called dentate while those without are known as edentulous (TAFE Queensland, 2016).

(c) List three (3) body systems that may be affected by the accidental ingestion of these medications.
Below is a list of the body systems vulnerable to accidental ingestion of medications. First, accidental ingestion of serepax can affect the respiratory system, the urinary system, the nervous system, the digestive system (Serepax Tablets, 2018).Secondly, when accidentally injected with metoprolol the body systems which are affected include the blood and cardiovascular system, the respiratory system, the integumentary system (Healthline, 2018). Additionally, wrongful ingestion with aspirin affects the blood and cardiovascular system, the digestive system, the respiratory system (WebMD, 2018). Finally, metformin affects the blood and cardiovascular system, the digestive system, the urinary system, the nervous system (Drugs.com, 2017).

Scenario 6 – Peter Jackson
Ruth and Michael Jackson have been trying to have a baby for the past five years. In November 2016, Ruth gives birth to a son, Peter. 48 hours after birth, Peter undergoes the standard neonatal screening test, which helps to identify those infants at risk of rare, but serious medical conditions such as phenylketonuria, hypothyroidism and cystic fibrosis.
Peter is found to have cystic fibrosis (CF), an autosomal recessive condition that affects mostly the lungs, but also the pancreas, liver, kidneys and small intestine.

Question 17.
(a) Discuss difference between having the disease of CF compared to being a carrier of CF from a genetic perspective.
Every cell has genetic information that gives coded information to the body to instruct to make protein. This will determine the look of the body, development and even works. This genetic information is stored on chromosomes, and human has 23 pairs of chromosomes in each cell. Moreover, they each have a pair which is made up of one copy of a chromosome from both parents. Cystic fibrosis is a recessive disease, and this results from a mutation in the gene. The mutation is responsible for production of cystic fibrosis transmembrane conductance regulator (CFTR) protein. If it happens an indivindual has a gene for CF only from a single parent, then they they will lack CF but will be a carrier. Moreover, the person who gets the disease will have a recessive gene for the mother as well as a father (Cystic Fibrosis Foundation, n.d.). To inherit CF, a person has double copy of CFTR gene containing mutation, one copy from both parents, i.e., each parent must have either CF or carrier of CFTR gene mutation.
For example :
F= normal gene dominant
f= recessive gene which will cause CF
Possible offspring genotype are
FF= normal (not a carrier)
Ff= means carrier (normal carrier)
ff= affected by CF(carrier) (Doc Brown, 2018)

Source: Zielenski, (2000)

Further Information:
At three months, Ruth and Michael take Peter to the paediatrician for a follow up. The paediatrician notes FTT (failure to thrive) on Peter’s medical record. She explains to the Jackson’s that this means Peter has poor weight gain, and that he will need a high calorie diet and enzyme supplementation for the rest of this life.

(b) Explain how CF causes failure to thrive and how this may impact on Peter’s biological maturation
CF influences failure as pancreases do not efficiently work and stop the body from absorbing calories or if the patient is consuming too few calories and at same time burns too many calories because of increased work of breathing. FTT means poor growth in short. In following way, failure to thrive will impact Peters biological maturation: Weight will drop approximately by 2% on the growth chart disimilar to the weight for age which becomes less by two% below the ideal, weight is below the third or fifth percentile, length weight is less than 80% of the ideal. Moreover, the weight height is less than the 3rd percentile and finally the height weight will be less than the 10th percentile (Alma, 2017).
(c) Why does Peter need a high calorie diet and pancreatic enzyme supplementation?
There are two main reasons why Peter needs supplementation of pancreatic enzyme and calorie diet. First, the failure to flourish in kids with cystic fibrosis happens due to the pancreatic deficiency and at the same time, these children are not able to absorb enough calories appropriately. Additionally, amplified work on breathing leads to the burning of extra calories (Alma, 2017).
(d)How does CF contribute to malabsorption of nutrients in a teenager?
Cystic fibrosis is a disease which is an inherited disease. This chronic disease affects two body systems respiratory (lungs) and digestive system (digestion). The difference between an average person and a person with cystic fibrosis is that they have a problem or difficulties in the salt and water exchange in cells. In addition, the condition leads to the body of the patient producing a thick and sticky mucus which has the ability of cloging the lungs and at times exposes the lungs to infections. To fight any infections, the body requires a large amount of calories. Mucus plays a significant role in prevention of pancreatic enzymes from getting through to the intestines consequently assisting in the absorption and digestion of food nutrients (Cystic Fibrosis Australia, n.d.). Due to this, a person can have maldigestion of food ultimately leading to malabsorption of nutrients in a teenager. As a result, this causes in teenage large bowel movements, slow growth and weight gain are also affected. Teens with CF require about 30-50 % more calories compared to regular teens, i.e., about 3000-5000 calories daily. Fat is the best source of the calories (“Cystic Fibrosis Foundation,” 2018).
Further Information:
Ruth is worried about Peter’s future and how long he is likely to live.
(e)What is the life-expectancy of a patient with CF, compared to a non-CF patient? How has current treatment affected this, compared to a patient diagnosed with CF twenty years ago?
Life expectancy of an individual with Cystic fibrosis compared to non-Cystic fibrosis patient is about 38 years (Cystic Fibrosis Australia, n.d.). Worldwide there are about 70,000 to 1,00,000 people who have cystic fibrosis. In recent years, there has been advancement in treatments available and provided to patients with cystic fibrosis. Primarily due to all improvement and early diagnosis, the lifespan of individuals suffering from cystic fibrosis has experienced improvement in the last 25 years. Few years ago many children with cystic fibrosis had little survival chances. In developed countries that include the United States and the United Kingdom, the average life expectancy is 35 to 40 years. Moreover, some patients have been able to live well beyond that. However, at the same time, the life expectancy is significantly lower in underdeveloped countries including El Salvador, India, and Bulgaria where it is less than 15 years (Cystic Fibrosis Worldwide, 2018).

(f) List three (3) common emergencies experienced by divers.

Divers experience numerous emergencies and the common ones include; Decompression sickness: Drivers sometimes ascent quickly in water instead of slow and controlled rise, because of which they inhale too much nitrogen which causes bubbles in the blood and tissues of the diver. Moreover, these bubbles create the reduction of blood flow and oxygen to keep tissues and organs alive.
Barotrauma: In this emergency during the ascent trapped air expands because of decreasing pressure which causes trauma to the diver. Moreover, it can occur in any body space filled with gas like eyes, ears, sinuses, dental structures, gastrointestinal tract, the pulmonary system including the dive mask and dive suit.
Shallow water blackout: During this emergency driver loses consciousness. Usually, this occurs during free driving (which means the driver uses no form of diving equipment) near the surface or just after surfacing. The shortage of oxygen and reduced carbon dioxide in blood causes hyperventilating before the dive increasing chances of unconsciousness (Queensland Government, 2016).

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