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Q575520

D. Maria, 28 anos, residente nas proximidades de um Programa de Estratégia Saúde da Família há 5 anos, procurou a unidade para uma consulta médica, queixando-se de mal-estar geral, dores nas articulações e febre esporádica. O enfermeiro da ESF a informou de que somente as famílias cadastradas naquela unidade poderiam usufruir dos serviços de saúde e a orientou a procurar outra unidade de saúde. Considerando essa situação e de acordo com o Artigo 196 da Constituição Federal, é correto afirmar que

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Q575549

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 situation described in the text by the author is an evidence that

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Q575517

Julgue os enunciados abaixo com base nas regras de pontuação. I. É obrigatório o uso das vírgulas na locução “por exemplo” (linha 17). II. Os parênteses (linha 18) são utilizados para isolar uma digressão. III. O travessão (linha 23) marca uma interrupção no pensamento do autor. IV. As aspas em “nuvem” destacam um emprego novo do termo, de sentido não usual. V. O uso das vírgulas que separam os complementos do verbo “manter” (linhas 12-13) é facultativo. Está correto o que se afirma em

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Q575524

A Resolução CONFEN nº 365/10 instituiu o Manual de Uniformização dos Atos Normativos do Sistema COFEN/Conselhos Regionais, com o objetivo de padronizar os documentos oficiais, seguindo uma estrutura linguística formal dentro de técnicas e modelos estabelecidos. Com base nessa Resolução, constitui-se norma de apresentação do padrão ofício usar

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Q575548

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

Carregando...
Q575523

No estado do Pará, em um assentamento de sem terras que conta com 300 famílias cadastradas e que não apresenta estrutura de serviços de saúde e saneamento básico, foi encontrada uma senhora, de 68 anos, que se intitulava auxiliar de enfermagem e prestava cuidados simples de enfermagem naquela comunidade. Tendo sido abordada por um profissional de saúde quanto ao exercício da profissão, informou ter o certificado de enfermeiro prático. Segundo o Decreto nº 94.406/87, é correto afirmar que o certificado de enfermeiro prático ou prático de Enfermagem foi

Carregando...
Q575547

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 word underlined in this passage of the text “I'm a nurse, so legally I cannot decide to increase a patient's dose of pain medication” means

Carregando...
Q575522

A Lei nº 7.498/86, em seu Art. 12, regulamenta as atividades de competência do Técnico de Enfermagem no exercício da profissão. De acordo com essa lei, é da competência desse profissional, exceto:

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Q575546

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 articles mentioned by the author of the text

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Q575521

A Enfermeira M.N.C, diplomada por uma Escola de Enfermagem de Portugal, foi aprovada em Concurso Público na Cidade de São Paulo para exercer atividades assistenciais no Hospital Público da Prefeitura. No momento da admissão no departamento de recursos humanos, contudo, os funcionários ficaram em dúvida quanto à validade ou não do seu diploma no Brasil. Para resolver o impasse, eles utilizaram, então a Lei nº 2.604/55, que regulamenta sobre o exercício da enfermagem no País e que expressa o seguinte:

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Q575545

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)

According to the text Don't Get Sick in July, medical errors increase in hospitals in July because July is the month when

Carregando...
GABARITO:

  • 1) A
  • 2) B
  • 3) B
  • 4) D
  • 5) A
  • 6) C
  • 7) C
  • 8) B
  • 9) C
  • 10) B
  • 11) D
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