THERE ARE 5 QUESTIONS OF MULTIPLE CHOICE IN YOUR TEST. EACH QUESTION HAS 4
ALTERNATIVES (A, B, C, AND D) FROM WHICH ONLY ONE IS CORRECT. CHECK THE CORRECT
ONE.
Don't Get Sick in July
By Theresa Brown
Published: July 15, 2012
It's one of those secrets you normally don't learn in nursing school: ''Don't go to the hospital in
July.'' That's the month when medical residents, newly graduated from medical school, start learning how
to be doctors, and they learn by taking care of patients. And learning means making mistakes.
There's disagreement in the medical literature about whether a so-called July Effect, where
medical error rates increase in the summer, actually exists. But a 2010 article in the Journal of General
Internal Medicine and a 2011 article in the Annals of Internal Medicine both found evidence of it. In an
interview, Dr. John Q. Young, lead author of the latter review, likened the deployment of new residents to
having rookies replace seasoned football players during ''a high-stakes game, and in the middle of that
final drive.''
From what I've experienced as a clinical nurse, whether or not the July Effect is statistically
validated as a cause of fatal hospital errors, it is undeniably real in terms of adequacy and quality of care
delivery. Any nurse who has worked in a teaching hospital is likely to have found July an especially
difficult month because, returning to Dr. Young's football metaphor, the first-year residents are calling the
plays, but they have little real knowledge of the game.
This experience deficit plays out in ways large and small, but I remember an especially fraught
situation one July when a new resident simply did not know enough to do his job and a patient quite
literally suffered as a result.
The patient was actively dying. He was old and his death was expected. He had kept his cancer
at bay for several years, but there were no more curative treatment options left and he had opted to die
peacefully in his bed, surrounded by his family. He had also wanted to die in the hospital, and his death
was coming on quickly enough that the hospital decided to allow it. He was grumpy, charming, funny and
impressively clear-eyed about the end of his life. During our brief, two-day acquaintance I developed a
strong attachment to him.
Death came closer quickly on that second day and as it neared, his pain increased significantly.
Dying from cancer often hurts. He needed oxygen to breathe comfortably, and because he was alert he
fully felt the intense pain.
I'm a nurse, so legally I cannot decide to increase a patient's dose of pain medication, but I can
call a physician and describe the patient's distress. That's part of a nurse's job, but there is also a chain
of command for getting medication orders, and another part of my job is adhering to that hierarchy.
I paged the first-year resident covering the patient. Since it was July he was an M.D. on the
books, but he was brand new to actual doctoring. I explained things, but he would not increase the
ordered dose. I paged him again. We talked over the phone, and I insisted. Then I pleaded. He would
not up the dose.
Looking at the situation from his point of view, I understand his reluctance. I was asking him to
prescribe a very large dose of narcotic, a killingly big dose if the patient was unused to opioids. The
resident might have learned in medical school about pain during dying, but he had not actually been with
a patient going through it. Seeing such pain -- the body twisting, the patient crying out helplessly -- is
categorically different from reading about it.
I also imagine the resident had been taught to prescribe narcotics judiciously, perhaps even
sparingly, and the amount of drug I was asking for was neither.
The patient's wife was kind; his daughter, a nurse, forthright. They and he deserved better than
they were getting, so I decided to take a risk. Ignoring the chain of command, I paged the palliative care
physician on call. She and I had talked about the patient the day before.
I described the patient's sudden lurch toward death, the sharp increase in pain and the resident's
reluctance to medicate the patient enough to give him relief. ''Ah,'' she said, ''I was worried about that,''
meaning that the patient might begin actively dying sooner than the medical team had expected. She
ordered a morphine pump. I got the drug, loaded and programmed the machine. The patient died fairly
soon after. He was conscious to the very end, and I can say he did not meet his death in agonizing pain.
A few hours later I ended up in the elevator with the new resident. He and I both started talking at
once. Looking stricken, he apologized to me for having been busy, overwhelmed with several new
patients. Knowing it is never easy to have someone's footprint on your head, I apologized for having
called in an attending physician. ''I don't usually jump the line,'' I started to explain, when he interrupted
me. ''You did the right thing for the patient,'' he said.
Such an exchange is rare. A nurse who goes over a doctor's head because she finds his care
decisions inappropriate risks a charge of insubordination. A resident who doesn't deliver good care risks
the derision of the nurse caring for that patient. Nurses aren't typically consulted about care decisions,
and this expectation of silence may lead them to lash out at doctors they see as inadequate.
The July Effect brings into sharp relief a reality of hospital care: care is becoming more
specialized, and nurses, who sometimes have years of experience, often know more than the greenest
physicians. We know about medicating dying patients for pain, but we know a lot of other things, too:
appropriate dosages for all kinds of drugs, when transfusions and electrolyte replacements are needed,
which lab tests to order and how to order them, whether consulting another specialist is a good idea,
whether a patient needs to go to intensive care because his vital signs are worryingly unstable.
The problem can be limited by better supervision from senior residents, fellows and attending
physicians, as well as by nurses. We need to acknowledge this fact, because admitting that new
residents need help, and that nurses can and do help them, is the beginning of owning up to our shared
responsibilities in providing care. For the good of our patients, nurses and doctors need to collaborate.
(http://query.nytimes.com/gst/fullpage.html?res=9C02E3DB143FF936A25754C0A9649D8B63&ref=nursingandnurses)
The underlined expression in the utterance “nurses, who sometimes have years of experience, often know more than the greenest physicians” refers to doctors who
The verb EMULATE in “or want to emulate another person” (third paragraph) means:
Read the following sentences:
1- English is not a priority on a teenager's to-do list,
__________?
2- Teenagers have a reputation for being difficult to
motivate, _______?
3- This strategy grabs their attention, __________?
4- The rappers' songs will sell, __________?
Choose the option that presents the right tag
questions that complete the sentences above,
respectively.
Choose the correct verb form that completes the
sentence below.
If the teenagers ________________ (not , drink) so
much beer last night, they wouldn't have had an
accident.
Read the text below and answer the question that follow.
Malala “defied their will”, so it means that:
Read the text below and answer the question that follow.
Read these sentences about Malala. Choose the sentence in which the present perfect has been INCORRECTLY used.
Read the text below and answer the question that follow.
Choose the alternative which presents the following sentence rewritten in the passive voice.
Someone has shot Malala near the school.
Read the text below and answer the question that follow
The noun NEWS was correctly used in “The news came one afternoon in May of 1993.” (§ 2) Choose the only correct sentence, as far as the use of the word NEWS is concerned.
The conjunction ALTHOUGH in “Although she’d been deeply hurt by the break up with her boyfriend” (§ 4) could be substituted, without change of meaning, for:
There are two occurrences of the word HARD in the text. The first one is in “[…] but it was really hard for me to be sympathetic […]” (§ 3). The second one is in “I studied hard […]” (§ 4). The word HARD in these sentences belongs to the following classes, respectively:
Consider the following paragraph:
“The set of practices, codes and values that mark a particular nation or group: the sum of a nation or group's most highly thought of works of literature, art, music, etc is referred to as _________ (1). The cultural dimension of language learning is an important dimension of second language studies. Education is seen as a process of socialization with the dominant culture. In foreign language teaching the culture of the _________ (2) may be taught as an integral part of the curriculum."
Choose the option which presents the two words that complete the paragraph above, respectively.
Questions 31 to 38 address both the teaching of English as a foreign language and the Parâmetros Curriculares Nacionais (PCNs)
According to the PCNs, one of the contributions of Cognitivism to the teaching of foreign languages is expressed by the:
In order to understand the core meaning of verbs, one must take into consideration the notions of time and tense. In the passage: “At the moment when the neon-pink sun slips below the horizon, everyone stops, stands and claps: a nightly salute to city, beach and sky.” (lines 5-7), the tense used conveys the idea of:
Conjunctions are items used to mark logical relationships between words, phrases, clauses or sentences. The conjunction which could be inserted before the sentence “I booked two tickets.” (line 30) in order to emphasize its logical relationship with the preceding sentence is:
Many English verbs consist of two parts: a lexical verb followed by one or two particles. In this way the only two phrasal verbs as they appear in the text are:
