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Nurse Practitioner Certification Examination and Practice Preparation 5th Edition Ebook PDF
Nurse Practitioner Certification Examination and Practice Preparation 5th Edition Ebook PDF
Nurse Practitioner Certification Examination and Practice Preparation 5th Edition Ebook PDF
Contributors
Acknowledgments
This book represents a sum of the efforts of many people. I thank Susan Rhyner, Amanda Minutola, and the F.A. Davis
I thank my family, especially my husband, and business staff for their ongoing encouragement.
partner, Marc Comstock, for their support and patience as Last but not least, I thank the thousands of nurse practi-
they lived through this experience. tioners who, over the years, have participated in the Fitzgerald
I thank the staff of Fitzgerald Health Education Associates Health Education Associates Nurse Practitioner Certification
for sharing me with this project for many months. To the courses. Your eagerness to learn, thirst for knowledge, dedi-
contributing authors, your insight has helped increase the cation to success, and commitment to excellence in healthcare
value and helpfulness of this publication. provision continue to inspire me. I am privileged to be part of
I thank the patients and staff of the Greater Lawrence your professional development.
(MA) Family Health Center, where I have practiced for more
than 30 years, as they continue to serve as a source of inspi-
ration as I developed this book. Gracias.
ix
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Preface
The scope of practice of the nurse practitioner is wide, encom- critical thinking skills needed for safe, entry-level NP practice.
passing the care of the young, the old, the sick, and the well. The reader is encouraged to answer the questions given in
This book has been developed to help the nurse practitioner each section and then check on the accuracy of the response.
develop the knowledge and skills to successfully enter nurse The discussion section is intended to enhance learning
practitioner (NP) practice and earn certification, an important through highlighting the essentials of primary care NP prac-
landmark in professional achievement. tice. The numerous tables can serve as a quick-look resource
This book represents a perspective on learning and prac- not only as the NP prepares for entry to practice and certifi-
tice developed during my years of practice at the Greater cation but also in the delivery of ongoing care.
Lawrence (MA) Family Health Center and as an NP and
professional speaker. In addition, my experiences through —MARGARET A. FITZGERALD, DNP, FNP-BC, NP-C,
the years of helping thousands of NPs achieve professional FAANP, CSP, FAAN, DCC, FNAP
success through conducting Fitzgerald Health Education President
Associates NP Certification and Advance Practice Update Fitzgerald Health Education Associates, LLC
Courses influenced the development and presentation of North Andover, Massachusetts
the information held within. Family Nurse Practitioner
This book is not intended to be a comprehensive clinical Greater Lawrence (MA) Family Health Center
text; rather, it is meant to be a source to reinforce learning Lawrence, Massachusetts
and a guide for the development of the information base and
xi
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Contents
Index 529
xiii
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6042_Intro_I1-I8 06/02/17 11:32 AM Page I-1
Introduction:
Understanding Test
Design and Theory
I-1
6042_Intro_I1-I8 06/02/17 11:32 AM Page I-2
good strategy might be to think of the question as a math Which answer included the best course of action for Sam?
problem or scientific equation with (patient) + (presentation) Let’s review the answers to see which one is correct and why.
+ (context) = (best action). Consolidating and storytelling
work for people who need to “talk through” answers and their A. Advise Sam to discontinue the current antimicrobial and
thinking to find the best result. Turn the question into a start a course of amoxicillin with clavulanate.
story and predict the ending before you look at the possible • Choosing this response infers amoxicillin treatment
answers. When in doubt, process of elimination can be a use- failure. AOM antimicrobial treatment failure is usually
ful exercise. By eliminating wrong answers, you can narrow defined, however, as persistent otalgia with fever after
down your choices by rereading the question with remaining 72 hours of therapy. Sam has taken fewer than 2 days
possibilities in mind. of therapy, an interval too short to assign continued
With the strategies we have covered here, let’s look at the symptoms to ineffective antimicrobial therapy. In
following test item: addition, there is no report of Sam’s condition wors-
You see 18-year-old Sam, who was seen approximately ening in the short time since he was initially seen.
36 hours ago at a local walk-in center for treatment of ear Therefore, prescribing an antimicrobial with a broader
pain. Sam was diagnosed with (L) acute otitis media, and spectrum activity, such as amoxicillin/clavulanate,
amoxicillin was prescribed. Today, Sam states that he is not warranted at this time. This is an excellent
has taken five amoxicillin doses since the medication was example of having a knowledge base that includes
prescribed but continues to have discomfort in the affected the standards of evidence-based practice is critical.
ear. Left tympanic membrane is red and immobile. B. Perform tympanocentesis and send a sample of the
This is an action-oriented question, directing you to con- exudate for culture and sensitivity.
sider Sam’s care and chief complaint. Based on the scenario • AOM treatment is based on empirical antimicrobial
presented, you can assume the following: therapy in which the clinician chooses an agent with
• Because no chronic health problems are mentioned, activity against the most likely organisms in a given
implied is that Sam is a young adult who is typically in condition, bearing in mind the most common resistant
good health. pathogens. Tympanocentesis is indicated only with
• Acute otitis media (AOM) is a common episodic illness treatment failure after 10 to 21 days of antimicrobial
usually caused by Streptococcus pneumoniae, therapy with a second-line agent, with the goal of
Haemophilus influenzae, Moraxella catarrhalis, or detecting a significantly resistant organism; at that
respiratory virus. point, culture and sensitivity of middle ear exudate
• A first-line antimicrobial for AOM treatment is amoxi- would be appropriate, usually with referral to otolaryn-
cillin. When given in a sufficient dose, this antibiotic is gology to have this procedure done. With fewer than
effective against S. pneumoniae and both H. influenzae 2 days of treatment, tympanocentesis is not indicated.
and M. catarrhalis that do not produce beta-lactamase. C. Have Sam return in 24 hours for reevaluation.
Nearly all M. catarrhalis and about 30% of H. influenzae • If Sam’s condition worsens in the next day, reevalua-
isolates produce beta-lactamase, rendering amoxicillin tion is prudent. However, choosing this option ignores
ineffective. Clavulanate is a beta-lactamase inhibitor, and Sam’s complaint of pain.
when given in conjunction with amoxicillin is an effective D. Recommend that Sam take an appropriate dose of ibupro-
treatment option when AOM fails to respond to amoxi- fen as needed for discomfort for the next 2 to 3 days.
cillin alone. • Choosing option D response infers that treating Sam’s
• As inflammation and purulent exudate forms in the pain is the most appropriate intervention. This is the
middle ear, a small space rich with pain receptors, otalgia best response and the correct answer.
is an expected finding in AOM. This usually resolves
Now consider this question: Which of the following
after 2 to 3 days of antimicrobial therapy.
best describes asthma? No clinical scenario is presented;
• Tympanic membrane immobility is a cardinal sign of
the question simply asks for a definition of a pathological
AOM that despite antimicrobial therapy does not resolve
state. When considering the options, the test taker must
for many weeks. A patient report of otalgia is also needed
recall that asthma is a chronic inflammatory disease of the
to make the AOM diagnosis.
airways involving an increase in bronchial hyperrespon-
The following answer choices are given:
siveness. This condition leads to a potentially reversible
A. Advise Sam to discontinue the current antimicrobial and decrease in FEV1-to-FVC ratio and is an example of how
start a course of amoxicillin with clavulanate. the NP boards often include questions on the clinical pres-
B. Perform tympanocentesis and send a sample of the entation of pathophysiology. This type of answer lends
exudate for culture and sensitivity. itself well to becoming a “true/false” question. As you read
C. Have Sam return in 24 hours for reevaluation. each answer, ask yourself whether a choice is true or false.
D. Recommend that Sam take an appropriate dose You are looking for the “true” answer. If answers seem par-
of ibuprofen as needed for discomfort for the next tially true, or true sometimes, select the one that is mostly
2 to 3 days. true, most of the time.
6042_Intro_I1-I8 06/02/17 11:32 AM Page I-4
Here are your answer choices: which you need to concentrate your review. If you have taken
an NP review course, you are likely aware that the content of
A. intermittent airway inflammation with occasional
certain parts of the program were truly review, whereas other
bronchospasm
sections helped to point out areas in which you needed to
B. a disease of bronchospasm leading to airway
expand on your knowledge base. Knowing on which areas to
inflammation
best concentrate your study helps you decide how to allocate
C. chronic airway inflammation with superimposed
your study time.
bronchospasm
As you study, please keep in mind that the NP certification
D. relatively fixed airway obstruction
examination tests your ability to know the following:
Let’s again look at the choices and reveal the correct • Why a patient is at risk for a problem.
answer. • How a clinical problem has developed.
• What is the most likely clinical presentation of the
A. intermittent airway inflammation with occasional
condition.
bronchospasm
• Why a given intervention is effective.
• Because asthma is a chronic, not intermittent, inflam-
• How that intervention works.
matory airway disease, this option is incorrect.
• What is the most likely clinical outcome.
B. a disease of bronchospasm leading to airway
• Why this clinical problem is of significance to the overall
inflammation
healthcare system.
• Because asthma is first a chronic inflammatory airway
A poor approach to preparing for the examination and
disease that leads to airway hyperresponsiveness, this
practice is to memorize information so you know what to do
option is incorrect.
but not why you are doing it, in both the examination room
C. chronic airway inflammation with superimposed
and as part of the larger healthcare system. A better approach
bronchospasm
to preparing for the examination and practice is to under-
• This option most closely matches the definition of
stand concepts and apply knowledge so you know what to do
asthma and is the best option.
and why you are doing it. The Fitzgerald Health Education
D. relatively fixed airway obstruction
Associates Inc. NP Certification Examination Review and
• Because the airway obstruction in asthma is largely
Advanced Practice Update prepares you in the why, how, and
reversible, this option is incorrect. This answer is more
what of NP practice, as well as helping to prepare you for suc-
descriptive of chronic obstructive pulmonary disease.
cess on the NP boards. Using this book will help greatly in
building your knowledge base so that you are able to apply
information to answer questions to help you in your pursuit
Review That Works of certification.
for You As you work through practice questions, and do this only
after working on building your knowledge base, make a note
With test design in mind, it’s time to think about planning next to each with words or symbols that indicate how certain
an effective study strategy. As you learned in your graduate you are of your answer. For some, you will be “sure” or “con-
studies, there are many “right” ways to study. The most fident” that an answer is correct; for others you may be
important factors to your success, regardless of learning style, “mostly” or “somewhat sure”; and for others, you are likely
depend on an organized and purposeful study plan. This issue offering a best guess. After you score your pretest, examine
of time needed for certification preparation is unique to each how your answers match up with your predicted perform-
examination candidate. That said, one of the major pitfalls in ance. If you marked yourself “confident” on an item you got
study is the failure to put aside the time to prepare. Map out wrong, start by studying the question and answer choices
the demands on your time in the first months after complet- carefully to glean the possible reasons you might have
ing your NP program, including work hours, family, personal selected the wrong answer for that particular question. Ask
and professional commitments, as well as time you have yourself the following: Did I understand the context prop-
perhaps set aside for some well-deserved downtime. After erly? If so, did I misinterpret or misread the question? Was
doing this, set up a schedule of study time, allotting a greater there unfamiliar content or vocabulary that led me to an
amount of time to areas of knowledge deficit and less to areas incorrect conclusion? What was it about the distractors that
in which you only need to refresh your knowledge base. Make distracted me? If you correctly answered a question about
sure you cover all areas listed as possible examination con- which you were not completely certain of the best answer,
tent. Plan your date for certification only after a period of ask yourself what information in the context, action, or
well-planned, systematic, certification-focused study. answer choices helped to lead you in the right direction.
Start with reviewing the information on the examination Frequent pretesting will not only help you to become more
content. Make a list of the areas in which you feel your knowl- comfortable on test day, it can also help you to be more effec-
edge base is secure and in which just reviewing material to tive at unlocking a question.
refresh your memory will likely suffice. Then make a second When studying for the NP boards, some people will work
list in which you identify areas of weaknesses and areas in best alone, whereas others benefit from collaborating with a
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study group. Study groups can be helpful and a terrific way other. The stress of preparing for an important examination
to share information and resources. Alternatively, study triggers the sympathetic nervous system to undergo Seyle’s
groups can yield a poor return on time invested if all mem- three phases of the general adaptation syndrome: alarm,
bers are not similarly committed. Study groups can meet in resistance, and exhaustion. In the alarm stage, perhaps trig-
person or virtually, such as via Skype or Google groups. The gered by contemplating the preparation needed to achieve
following contains some guidelines for forming a successful certification success, the hypothalamus activates the auto-
study group. nomic nervous system, triggering the pituitary and the body
All group members must treat attendance and participa- defenses, resulting in a heightened sense of awareness of
tion as they would any other professional commitment, such surroundings, alertness, and focus. At this level of arousal,
as work or school. Well in advance, set a schedule, place, and studying for and taking a test often yield great results. A well-
time to meet, as well as a topic for the meeting. Plan a start prepared examination candidate is highly focused on what
and end time, with a clear objective for the session. Study needs to be done to be successful on the examination. Dis-
groups usually work best when a group member volunteers tractions can be filtered out; extraneous information can be
to research and present information on a subject on a prede- discarded in favor of the essentials. During the examination,
termined schedule. The presentation is typically followed by anxiety and knowledge intersect; information retrieval is
a discussion of the issue and a review of sample examination facilitated, and examination questions are fluidly processed.
questions and rationales for the correct response. The leader Difficult examination items are usually put in perspective,
of a given session should also assume responsibility for keep- with the test taker recognizing that most items were answered
ing the discussion on track, facilitating the efficient use of with relative ease. The NP certification candidate emerges
time and resources. from the test feeling challenged but confident.
To help avoid the group deteriorating into a chat session, Although a moderate amount of anxiety is natural, and
plan for a short period of socialization following high-yield even useful, many candidates can find themselves struggling
study sessions. Here is an example of a session planned by a with anxiety that is causing physical or emotional distress.
successful study group with three members, Sarah, Ben, and The process of completing a rigorous course of graduate
Helena. “The session will start promptly at 7 p.m. and end at education and study can result in a protracted period of
9 p.m., with the objective of identifying the risk factors, clin- stress. Now, the formerly helpful stress leads to the second
ical presentation, assessment, and intervention in commu- stage of the general adaptation syndrome, resistance, in which
nity-acquired pneumonia in the adult. Sarah is the presenter epinephrine is released to help counteract or escape from the
and also group leader for the evening and is responsible for stressor. At that time, the feeling of milder anxiety present in
keeping us on track. A social period from 9 to 9:30 p.m. will the first stage gives way to a sense of greater nervousness,
follow. We will meet at Helena’s apartment. Ben is responsi- often accompanied by uncomfortable physical sensations
ble for refreshments.” such as dry mouth, tachycardia, and tremor. Studying or test
Whenever possible, try to create a study situation that will taking becomes difficult; information retrieval is inhibited.
mimic the actual test. Set a timer and be mindful of pacing This stage is mentally and physically taxing and, if left
yourself. During the test, expect to answer about 60 to 70 or unchecked, can lead to exhaustion, complicating the chal-
more multiple-choice questions per hour. This means you lenging task of successfully completing the certification
will likely be spending less than a minute, on average, on examination. Although the reaction is most severe at the time
each question. Some questions take only a few seconds, of the test, most people who have severe test-taking anxiety
whereas others require more time for thought. Check yourself have a similar, although milder, reaction with the deep study
at 15- or 20-minute intervals to determine whether you needed to prepare for a critical examination such as NP
are progressing at an acceptable rate, setting a number of certification.
questions that you should have answered by a certain time. The following scenario describes a person with a problem-
atic case of studying-testing anxiety:
The NP certification examination candidate is having a tough
Managing Nerves day, with a work shift that stretched for 3 unexpected hours and
an unusually long commute, all following a poor night’s sleep as
During Review and a result of a noisy neighborhood party. To counteract this, the
on Test Day candidate drank a few extra cups of strong coffee and drank an
“energy drink,” really nothing more than a can of sugar and
Everyone who sits for one of the certification examinations caffeine. She also skipped lunch and made a quick trip to a fast-
food restaurant for some fries as a snack. Studying was part of
is anxious to some degree. This anxiety can be a helpful emo-
today’s plan, however, so she sits down to prepare for the
tion, focusing the NP certification candidate on the task at examination with great intentions of reviewing critical
hand: studying and successfully sitting for this important information. Surrounded by great stacks of study material, the
examination, a tangible end product of the candidate’s grad- NP candidate thinks about what might be on the examination
uate or postgraduate education. When excessive, however, and ponders the wide scope and knowledge base needed to be
anxiety can get in the way of success. Stress yields anxiety, successful. Now the candidate becomes aware of a dry mouth and
anxiety yields stress; one can be viewed as the product of the tight feeling in the throat. Determined, she sits down and decides
6042_Intro_I1-I8 06/02/17 11:32 AM Page I-6
to study about antimicrobial therapy. The words on the page test day with an empowered mind-set can help alleviate fears
seem to blur when the candidate tries to read about the spectrum and prepare you for what lies ahead. Let’s assume you have
of activity of an antibiotic; then, having difficulty keeping this devoted a large amount of time to a purposeful and organized
information straight, she decides to skip that and focuses on study regimen, and you are starting to think about the test day
memorizing a few antibiotic dose ranges, information that is
itself. Coaches often advise their athletes to avoid anything new
unlikely to be on the boards. Even with repeated tries, the NP
on game day. You will be wise to heed this advice as well. This
candidate cannot keep this information at hand and now
becomes even more anxious, feeling tension in the back of her is not the time to change your diet, caffeine intake, medica-
neck and a rapidly beating heart. The candidate now tries a few tions, or sleep schedule. The test environment will be different
practice examination questions but answers three questions from what you are used to, so try to keep your routines as close
about the appropriate use of antimicrobial therapy in acute otitis to “normal” for you as possible.
media incorrectly. Now, even the thought of sitting for the Visit the Web site of the certifying body to learn all that
examination causes the NP candidate to freeze. you can about test center rules, what you are and are not
In an ideal world, we could all control schedules and set allowed to bring to the test site, and information about pacing
aside vast periods of calm, focused review. Life, however, is and breaks. Usually the testing agency has a “test drive” video
complicated. Although developing a study schedule is impor- of what to expect with the examination software and the like.
tant, rescheduling study time is likely a good idea when a day On test day, leave yourself plenty of time to arrive at your test
has been particularly difficult. Trying to learn when exhausted center, get settled, and enter the test without feeling rushed.
and stressed by other influences is often counterproductive. Be sure to have a government-issued photo ID as well as
Certain scents can be helpful for putting the NP candidate in copies of all confirmation numbers and e-mails from the test
the right frame of mind to study, particularly under less-than- center or organization. Expect that video surveillance will be
ideal conditions. These include basil, cinnamon, lemon, and used in test centers to limit fraud and ensure security. At
peppermint for mental alertness and chamomile, lavender, many test centers, you will be asked to empty your pockets
and orange for relaxation. and place all personal items in a locker provided for your use.
Learning a relaxation technique to use before studying or As part of your review, you should have some practice
test taking can help you start your review session with a clear pacing yourself as you answer the test questions. Remember,
mind and shift your focus from whatever events or stress your you will have about 1 minute per test item. Don’t get bogged
day may have contained. You can also employ these same down on a question or questions part of the way through the
techniques on test day to help center yourself if you feel over- examination. If you are stumped by a question, use the testing
whelming anxiety begin to creep in. Start the session by read- software’s highlighting option to mark the question, answer
ing or repeating a positive message about being successful on the question to the best of your ability, move on, with a plan
the examination. Avoid excessive amounts of caffeinated to return to this item at the end of the test. Do not be sur-
beverages prior to studying, which can add to anxious feel- prised if you highlight more questions earlier in the exami-
ings. Eat a light but nourishing meal containing complex car- nation and less as you progress and are more comfortable
bohydrates, fruits or vegetables, and high-quality protein to with the test format and your brain is “warmed up.” Remind
feed the body and mind. Avoid refined sugars and excessive yourself that you have answered many questions with relative
fat intake, which can sap energy and derail quality study. ease. Finish all of those questions that you can answer and
The NP candidate’s anxiety started when pondering the then come back later to process the problematic questions.
wide range of possible topics on the certification examina- Expect that the topics you studied will be presented in ran-
tion. Starting the session by studying a narrowly focused topic dom order. A question on diabetes mellitus follows one on
with a specific outcome goal rather than simply studying hypertension and can be preceded by a question on women’s
might have averted this. Setting up a system of study can health.
enhance the success of a study session further. One method Preparing for and taking the NP certification examination
is the SQ4R system, in which one surveys the study informa- takes focus, determination, and courage. You have devoted
tion to establish goals; formulates questions about the infor- years of study and months of preparation to this endeavor.
mation; and then reads to answer these questions, followed by Approaching test day with an empowered mind-set can help
reciting the responses to the original questions, and reviewing alleviate fears and prepare you for what lies ahead. Emphasize
to see whether the original goals were met. Study and test- context and adaptive expertise over memorization, become
taking anxiety can also be tamed with the help of a learning a master at “unlocking” test questions, and be honest with
specialist who can work with the NP candidate to develop the yourself about your learning style and study habits as you
needed skills. Learning specialists can usually be contacted prepare to set yourself up for the best outcome.
through the academic support centers at universities. Consider these clinical practice and certification tips as
you prepare:
• Remember that common disease occurs commonly and
Test Day that the uncommon presentation of a common disease
is more common than the common presentation of an
You have devoted years of study and months of preparation to uncommon disease. The fundamental tools of NP prac-
this day, and this very thought can be daunting. Approaching tice include the ability to procure comprehensively yet
6042_Intro_I1-I8 06/02/17 11:32 AM Page I-7
succinctly the information needed to develop accurate • Remember to address a patient’s primary, secondary,
diagnoses. Gathering the needed subjective and objective and tertiary healthcare needs at every visit. Check for
information in the care of a person with common acute, needed immunization, screening tests, and follow-up on
episodic, and chronic health problems is the most impor- previous health problems with every encounter. Think
tant skill the NP can develop. Develop the skill of taking a long-term. Envision working with patients during the years
thorough yet concise health history that is pertinent to the ahead and the health problems you may help a person
patient’s presenting complaint or health problem. As you avoid by working together. The healthcare provided by the
proceed through the history, recall the rationale behind NP is guided by health and wellness research. The NP is
each question you ask and how a given response impacts accountable for his or her ongoing learning and profes-
the possible etiology of the patient’s health problem. Know sional development and is a lifelong learner. The NP is
how to perform a thorough yet succinct symptom analysis. also knowledgeable in accessing resources to guide
It is during this process that the detective work of diagnosis evidence-based care.
starts. Use the physical examination to confirm the • Ask preceptors and peers what references are most
findings of the health history. helpful for that particular practice. Armed with this
• Remember that the physical examination is guided by information, develop your own reference library that you
the health history, not the other way around. The NP can use with ease. Your investment in the time and money
has the responsibility of arriving at a diagnosis, developing it may take to gather these resources will pay off in your
a treatment plan, and providing ongoing evaluation of practice.
response to treatment. Using these principles as you study for your NP boards
• To maximize your experience in your clinical rotations, will increase your likelihood of success with certification as
learn to recognize the typical presentation for the well as your transition to NP practice. Good luck—the world
10 most common health problems that present to is waiting for the contributions that you will bring!
your practice site, including chief complaint and
physical examination findings, differential diagnosis,
needed diagnostics, intervention, and ongoing evalua- References
tion. Armed with this information, you can focus your
study on a thorough knowledge of the assessment and Nugent P, Vitale B. Test Success: Test-Taking Techniques for
treatment of these conditions. As an adult learner, carry- Beginning Nursing Students. 6th ed. Philadelphia, PA:
ing this applied learning to the boards helps make your NP F.A. Davis; 2012.
education come alive. Bloom BS, ed. Developing Talent in Young People.
Ask your preceptor to save laboratory results, ECGs, and New York, NY: Ballantine Books; 1985.
other diagnostics for you to review at the next session. Do so Hatano G, Inagaki K. Two courses of expertise. In: Stevenson
with a clean eye, as if you were developing a plan of interven- H, Azuma H, Hakuta K, eds. Child Development and
tion or further diagnosis for the patient. This will help hone Education in Japan. New York, NY: Freeman; 1986.
your clinical skills. If you prescribed an intervention but will Mastering tests. http://web.mit.edu/uaap/learning/test/
not have the opportunity to see the patient at a follow-up index.html.
visit, ask your preceptor for an update. Family, cultural, Sefcik D. How to Study for Standardized Tests. Sudbury,
community, developmental, and environmental factors as MA: Jones & Bartlett; 2012.
well as lifestyle and health behaviors influence patient health Taking multiple choice exams. http://people.uwec.edu/
and the interaction between the NP and the patient. As an ivogeler/multiple.htm.
advanced practice registered nurse, the NP provides holistic, Test-taking strategies. https://casc.byu.edu/testtaking-
wellness-oriented care on an ongoing or episodic basis. strategies.
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6042_Ch01_001-024 06/02/17 11:56 AM Page 1
Health Promotion
and Disease Prevention 1
6. Active immunity is defined as:
Health Promotion A. resistance developed in response to an antigen.
and Disease B. immunity conferred by an antibody produced in
another host.
Prevention C. the resistance of a group to an infectious agent.
1. An example of a primary prevention measure for a D. defense against disease acquired naturally by the
78-year-old man with chronic obstructive pulmonary infant from the mother.
disease is: 7. Which of the following is usually viewed as the most
A. reviewing the use of prescribed medications. cost-effective form of healthcare?
B. conducting a home survey to minimize fall risk. A. primary prevention
C. checking FEV1 (force expired volume at 1 second) B. secondary prevention
to FVC (forced vital capacity) ratio. C. tertiary prevention
D. ordering fecal occult blood test (FOBT). D. cancer-reduction measures
2. Which of the following is an example of a primary 8. An 18-year-old woman with allergic rhinitis presents for
prevention activity in a 76-year-old woman with primary care. She is sexually active with a male partner
osteoporosis? and is 1 year post-coitarche; during that time she had
A. bisphosphonate therapy two sex partners. An example of a primary prevention
B. calcium supplementation activity for this patient is:
C. ensuring adequate illumination in the home A. screening for sexually transmitted infection.
D. use of a back brace B. counseling about safer sexual practices.
3. Secondary prevention measures for a 78-year-old man C. prescribing therapies for minimizing allergy.
with chronic obstructive pulmonary disease include: D. obtaining a liquid-based Papanicolaou (Pap) test.
A. screening for mood disorders. 9. When a critical portion of a population is immunized
B. administering influenza vaccine. against a contagious disease, most members of the
C. obtaining a serum theophylline level. group, even the unimmunized, are protected against
D. advising about appropriate use of car passenger that disease because there is little opportunity for an
restraints. outbreak. This is known as _________ immunity.
4. Tertiary prevention measures for a 69-year-old woman A. passive
with heart failure include: B. humoral
A. administering pneumococcal vaccine. C. epidemiologic
B. adjusting therapy to minimize dyspnea. D. community
C. surveying skin for precancerous lesions.
D. reviewing safe handling of food.
Answers
5. Which of the following products provides passive
immunity? 1. B. 4. B. 7. A.
A. hepatitis B immune globulin (HBIG) 2. C. 5. A. 8. B.
B. measles, mumps, and rubella (MMR) vaccine 3. A. 6. A. 9. D.
C. pneumococcal conjugate vaccine
D. live attenuated influenza vaccine (LAIV)
1
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NO sooner had the door closed on Cicely and her little cousin than
Mrs. Crichton’s pent-up curiosity broke forth. She overwhelmed her
brother with questions and cross-questions as to the how, where,
and when of his former acquaintance with Miss Methvyn, till Mr.
Guildford was fairly driven into a corner. He defended himself
valiantly for some time; he tried short answers, but even
monosyllables failed in their usually chilling effect on the irrepressible
Bessie. She was not to be snubbed; she only grew increasingly
pertinacious and finally cross.
“It is too bad of you to be so absurdly reserved with me, Edmond,”
she said at last. “You are not a doctor now; I am not asking you to
gossip about your patients. You will make me suspect something
mysterious if you don’t take care.”
Then Edmond saw that his best policy would be to volunteer as
much information as it suited him that his sister should be in
possession of, knowing by experience that to baffle temporarily her
curiosity was surely to increase it in the end. Hydra-like, it but
sprouted afresh in a hundred new directions, if extinguished in one;
and that she should even suspect the existence of anything he
wished to conceal, with regard to Cicely, was disagreeable and
undesirable in the extreme. So he smiled at her petulant speech, and
answered good-humouredly. “I know what you always mean by
something mysterious, Bessie. You are constantly fancying you have
got on the scent of a love-story. I have no love-story to confide to you
about Miss Methvyn—at least—” he stopped and hesitated.
“At least what?” exclaimed Mrs. Crichton.
“I was thinking,” he said, “of what you said about my not being a
doctor any longer. That does not make me free to gossip about what
I became acquainted with when I was one, does it?”
“No, I suppose not,” said Bessie. “But I shall never tell over
anything about Miss Methvyn. I want to know about her, I have taken
a fancy to her. Do go on after ‘at least.’ ”
“I was merely going to say that the only love-story I can tell you
about her, is painful and must not be alluded to. But under the
circumstances, perhaps, it is best you should know it. When I last
saw Miss Methvyn, she was on the point of marriage with her cousin,
a Mr. Fawcett—the marriage was broken off, and within a very short
time he married another girl—her cousin, but not his, a French girl,
the daughter of these people here, the pasteur and his wife.”
“What a shame!” ejaculated Bessie. “I thought they seemed such
nice people.”
“So they are, I have no doubt. If not, she—Miss Methvyn—would
not be staying with them.”
“But the girl—their daughter—must have been very designing.”
Mr. Guildford did not answer. “How dreadful for Miss Methvyn!”
continued Bessie. “I wonder it did not break her heart.”
“How do you know it didn’t?” asked her brother quickly.
“She doesn’t look like it,” said Mrs. Crichton. “She looks grave and
rather sad, but she smiles brightly; there is nothing bitter or sour
about her.”
“She has had troubles enough of other kinds to make her grave
and sad. Though, indeed, her face always had that look when in
repose,” he said thoughtfully. “Bessie,” he went on, with a sudden
impulse of communicativeness, born of a yearning for sympathy, “do
you remember one night, nearly two years ago, when I had to go out
into the country beyond Haverstock—a very cold night?”
“Yes,” said Bessie, “I remember it—a little child was very ill. It
died, I think.”
“That night was the first time I saw Miss Methvyn.”—“Standing
with that crimson dress on,” he murmured to himself softly. “Yes,” he
went on aloud, “the child died. He was her nephew. And since then
she has lost father and mother and her home too.”
“Poor girl!” said Mrs. Crichton, with the ready tears in her eyes.
“By the bye,” she added in a brisker tone, “was she Miss Methvyn of
Something Abbey? I never can remember names.”
“Greystone?” suggested her brother.
“Yes, to be sure. I knew it was a colour, black or white or
something. Oh! then, I know about them a little. Some friends of the
Lubecks bought Blackstone, and are living there now. It was sold
because when the father died, they found he had lost a lot of money
—in horse-racing, wasn’t it?”
“Not exactly,” said Mr. Guildford, smiling. “The poor man had been
paralysed for some years. But he did lose money by speculation—
that was true enough. What else did you hear?”
Bessie’s brain was not the best arranged repository of facts in the
world, but by dint of diving into odd corners, and bringing to light a
vast mass of totally irrelevant matter, she managed to give her
brother a pretty clear idea of what she had learnt about the
Methvyns’ affairs. And joining this to what he already knew, Mr.
Guildford arrived at a fair enough understanding of the actual state of
the case. “I don’t believe it was her loss of fortune that separated
them,” he said to himself; “she is not the sort of girl to have allowed
that to influence her. And he—if it had been that—would not have
married a completely penniless girl immediately after. No, it could not
have been that. He must have deceived her—how she must have
suffered! Yet, as Bessie says, I don’t think she does look broken-
hearted.”
He fell to thinking of how she did look. He was silent and
abstracted, but Bessie asked no more questions. Her curiosity was
so far set at rest, but it is to be doubted if her brother’s carefully
considered communicativeness had satisfied her of the non
existence of her “something mysterious.” But she was loyal and
womanly, despite her inquisitiveness; her brother’s secret, if he had
one, was safe.
During the rest of the day, Mr. Guildford was restless and ill at
ease. . He was constantly acting over again the morning’s interview
with Cicely, and wishing that he had said or done differently.
Sometimes it seemed to him that his manner must have appeared
almost rudely repellent and ungracious; at others, he reproached
himself with having behaved with unwarrantable freedom.
“I did not even shake hands with her,” he remembered. “Rude
boor that I am. As if I had any business to annoy her by my absurd
self-consciousness, when she was so sweet and gracious and
unaffected—so evidently anxious to be just as friendly to me as if I
had never made a fool of myself. Of course, it is easy for her to be
unconstrained and at ease with me—there is no reason why she
should not be so—the question is whether I shall ever attain to it with
her.”
Then he grew hot at the thought of having allowed her to copy his
papers—actually to work for him—and ended by saying to himself
that he devoutly wished he had not come into the room, or that,
better still, Bessie had held her silly little tongue about his
occupation. Yet all the time he was looking forward with
unacknowledged eagerness to the next day, cherishing a foolish
hope that Cicely might herself bring back her completed work, or that
possibly she might find it necessary to apply to him for information or
instruction upon some difficult part of the manuscript. And when the
next day came, and the papers, beautifully written, and perfectly
correct, were brought to the Rue St. Louis by old Mathurine, with a
little note from Cicely, hoping that Mr. Guildford would not hesitate to
return them if in any way faulty, he felt a pang of disappointment
which startled him into acute realisation of the fact that he was as
ready as ever, nay, ten times more so, to “make a fool of himself” for
this woman, whom he thought he had grown indifferent to. “It is as if
some one that one had thought dead had come to life again. It is
very hard upon me. For more than a year I have thought of her as
Fawcett’s wife, as more than dead to me, and now the old struggle
must begin again.”
But after a time he grew calmer. The events of the last two years
had altered—some superficial observers might have said, weakened
—this man, once so strong a believer in his own opinion, so
confident in his own power of acting up to it. But if he were
weakened, the weakness was that arising from a greater knowledge
of himself, a juster estimate of human nature, a nobler, because truer
ideal—it was a weakness promising strength. He was less given to
make theories, less loftily determined to live the life he sketched out
for himself. “I am well punished for my presumption in thinking I was
stronger than other men, or that in such strength there was nobility.
Here am I at thirty with powers already curtailed, thankful now not to
be threatened with a future of utter dependence. Here am I who
despised and depreciated woman’s influence—feeling that without
the love of a woman who will never love me, life, in no one direction,
can be other than stunted and imperfect. Yes, I am well punished!”
And it was through this last reflection that he attained to a more
philosophic state of mind. If the disappointment which this love of his
had brought upon him, were a recompense merited by his self-
confidence and self-deception, what could he do but accept it? what
more futile than to waste his strength of mind in going back upon a
past of mistakes and might-have-beens? Why not exert the self-
control he possessed in making the best of what remained, in
enjoying the friendship which Cicely was evidently ready to bestow
upon him, with which, in her altered circumstances, there was little
prospect of any closer tie coming into collision?
“I dare say she will never marry,” he said to himself with
unconsciously selfish satisfaction. “She is not the sort of woman to
‘get over’ such an experience as she has had, in a hurry. I doubt if
she will ever do so. Her very serenity looks as if she had gauged her
own powers of suffering pretty thoroughly, and had now reached a
tableland of calm—I feel sure she will never marry. I should like to
show her that I am able to value her friendship, and that she need
have no fear of my ever dreaming of anything more. I should like her
to respect me.”
So, considerably to Bessie’s surprise, a day or two after the
papers had been despatched, her brother proposed that they should
return Monsieur and Madame Casalis’s call.
“I should like to thank Miss Methryn personally,” he said calmly.
“And I am sure her relations are kind, good sort of people from what
you tell me. It was very civil of them to call. I should not like them to
think me a surly hypochondriac.”
“But are you fit for it?” said Mrs. Crichton, hardly able to believe
her ears.
“Fit to make a call?” he exclaimed, laughing. “Of course I am;
there’s nothing wrong with me now except my eyes, and they are
much better. They never pain me now unless I read or write. I don’t
want to drive there, Bessie,” he went on, “we can walk. It is only two
or three streets off.”
“Very well,” said Bessie, in her heart nothing loth to see
something more of their only acquaintances at Hivèritz. She looked
up at her brother curiously. “I wonder if Edmond has anything in his
head that he hasn’t told me,” she thought. But Edmond met her
glance with perfect self-possession. He felt that he had no motive of
the kind that she evidently suspected; he only wished to return to his
old friendly relations with Cicely Methvyn; there was no fear of
further self-deception. He was satisfied that, having now recovered
from the first surprise of meeting her again, he was in a fair way of
attaining to a composed and comfortable state of mind with regard to
this girl, whose path and his had once more so unexpectedly
crossed each other.
So Bessie was fain to suppose that her discrimination had
actually been at fault, and that her brother was uninfluenced by any
other motives than those he averred. And for some time to come,
there was nothing to disturb her in this opinion. They called on
Madame Casalis, and found both her and Miss Methvyn at home,
and the half-hour spent in the modest little drawing-room in the Rue
de la Croix blanche, was a very pleasant one, and Mr. Guildford
returned home well contented with himself, and satisfied that Cicely
tacitly appreciated his resolution.
“She has great tact,” he thought; “her manner is so simple and
unconstrained that it makes it infinitely easier for me.”
And for her part, Cicely was saying to herself that things were
turning out just as she had hoped—Mr. Guildford had evidently quite
forgotten all about that passing fancy of his; he wished—by his
manner she could see that he wished—to be thoroughly friendly and
kind; he was a man whose friendship any woman might be proud of
possessing. And as she thought thus, there flitted across her mind a
vague recollection of something she had once said to him on this
subject of friendship—it was one summer’s day in the garden at
Greystone—and Mr. Guildford had been expounding for her benefit
some of the wonderful theories which he then believed in so firmly.
She remembered all he had said quite well (how little she suspected
what bombastic nonsense it now appeared to him!), and she
remembered, too, that what she had replied had made him declare
he had converted her. It was something about feeling more honoured
by the friendship than by the love of a man capable of friendship of
the highest kind.
“I did not say it so plainly,” thought Cicely, “but that was the sense
of it. I know I was rather proud of the sentiment. I wonder if Mr.
Guildford remembers it. I do think him a man whose friendship is an
honour; and it is much better that I should henceforth keep clear of
anything else. I have had storms and troubles enough. Only—only—
sometimes life looks very lonely now.”
But during the remainder of this so-called winter, life passed on
the whole pleasantly enough. The acquaintance between the two
families progressed to friendliness; then to intimacy, till there were
few days when some of their members did not meet. Cicely owned to
herself that the society of the brother and sister added much to the
interest of her otherwise somewhat monotonous life; and Mr.
Guildford, having thoroughly shaken himself free from any possibility
of further self-deception, allowed himself to enjoy Miss Methvyn’s
friendship without misgiving, and day by day congratulated himself
more heartily on the strength of mind with which he had recognised
his position and bravely made the best of it. Only Bessie,
commonplace, womanly, silly little Bessie, sometimes looked on with
vague uneasiness, now and then trembled a little at the thought that
perchance this pleasant present might contain the elements of future
suffering.
“Edmond doesn’t think he is in love with her,” she said to herself,
“and he certainly gives her no reason to think he is. But he has it all
his own way just now; how would it be if some rival turned up all of a
sudden, would not that open his eyes? And though she has been
unlucky once, it is unlikely she will never marry. I could not bear
Edmond to be made miserable. If she were less high-principled and
thought more of herself, I would fear less for him.”
Once or twice there occurred little incidents which increased the
sister’s anxiety, and of one of these she was herself in part the
cause. Little Mrs. Crichton, “stupid” as she called herself, had one
gift. She possessed an unusually beautiful voice. It was powerful and
of wide compass, but above all clear and sweet and true, and with a
ring of youth about it which little suggested her eight-and-thirty years.
She sang as if she liked to hear herself; there was no shadow of
effort or study of effect discernible in the bright, blithe notes, which
yet at times could be as exquisitely plaintive. Cicely, who loved
music more, probably, than she understood it, soon discovered this
gift of her new friend’s, and profited thereby, thanks to Bessie’s
unfailing good-nature, greatly. She was never tired of Mrs. Crichton’s
singing.
“I am glad you like my sister’s voice,” said Mr. Guildford one day,
when Bessie had been singing away for a long time. “I like it better
than any I ever heard, but then I am no judge of music.”
“Nor am I. But in singing one knows quickly what one likes,” said
Cicely. “I have heard a great many voices—some wonderfully
beautiful no doubt, but I never heard one I liked quite as much, or in
the same way, as Mrs. Crichton’s.”
Mr. Guildford looked pleased. “Don’t leave off, Bessie,” he said,
“not, at least, unless you are tired.”
“What shall I sing?” said Bessie, turning over the loose music
lying before her. “Ah! here is one of your favourites, Edmond, though
I don’t think it very pretty. You must judge of it, Miss Methvyn. I have
not sung it lately. Edmond has got tired of it, I suppose. At one time
he was so fond of it, he used to make me sing it half-a-dozen times a
day.”
She placed the song on the desk, and began to sing it before her
brother noticed what she was doing. When he heard the first few
bars, he got up from his seat and strolled to the window, where he
stood impatiently waiting for a pause. Bessie had hardly reached the
end of the first verse before he interrupted her. “I am sure Miss
Methvyn will not care for that song, Bessie,” he exclaimed. “Do sing
something else.”
He crossed the room to the piano, beside which Cicely was
standing, and opened a book of songs which lay on the top. Mrs.
Crichton left off singing, but turned towards her brother with some
impatience. “You are very rude, Edmond,” she exclaimed with half
playful petulance. “You should not interrupt me in the middle of a
song. And you are very changeable—a very few months ago you
thought this song perfectly lovely. Do you like it, Miss Methvyn?” she
inquired, turning to Cicely. “The words are pretty.”
“Are they?” said Cicely, “I don’t think I caught them all. Yes, I think
the song is rather pretty—not exceedingly so.”
“The other verses all end in the same way,” said Bessie, humming
a note or two of the air; “that is the prettiest part, ‘Cicely, Cicely
sweet.’”
Cicely gave an involuntary little start, but she did not speak. Mr.
Guildford turned over the leaves of the book with increasing energy.
“Here, Bessie, do sing this,” he exclaimed, placing another song in
front of the tabooed one on the desk.
“No, I won’t,” said Bessie obstinately, “not till I have finished
Cicely. I can’t understand your being so changeable—it was such a
favourite of yours.”
“One outgrows fancies of the kind,” observed Cicely quietly. “Our
tastes change. I dare say it is a good thing they do.”
“Do you think so?” said Mr. Guildford quickly. “I don’t quite agree
with you. My tastes do not change, and I do not wish them to do so.”
He looked at her as he spoke. Cicely felt her cheeks flush, and
she turned away. Bessie went on singing. By the time the song was
over, Cicely, glancing up again, saw that Mr. Guildford had quietly left
the room.
“How cross Edmond is!” said Bessie, getting up from the piano
pettishly. Suddenly a thought struck her. “Miss Methvyn,” she
exclaimed abruptly, “your name isn’t ‘Cicely,’ is it?”
“Cicely did not immediately answer. “I never thought of it before,”
Mrs. Crichton continued; “it just struck me all at once that I had heard
Madame Casalis call you by some name like it, but she pronounced
it funnily.”
“She very often calls me Cécile,” replied Miss Methvyn quietly.
“But my name is Cicely.”
Bessie was silent. Then suddenly she turned to Cicely and laid
both hands on her arm entreatingly. “Miss Methvyn,” she said,
“Edmond is like a son to me. I could not bear him to be miserable.
He is not a man to go through anything of that kind lightly. Forgive
me for saying this.”
“There is nothing to forgive,” replied Cicely. “But I think you are
mistaken. Mr. Guildford is not a boy, he is wiser than either you or I.”
Bessie hardly understood these rather enigmatical words, but she
dared say no more. After that day, however, she could never find her
brother’s favourite ballad again; it disappeared mysteriously.
And things went on as quietly as before. Mr. Guildford’s health
seemed perfectly reestablished, and even his eyesight failed to
trouble him. He gave himself a holiday for the remainder of his stay
at Hivèritz, and the days passed only too pleasantly. There were all
manner of simple festivities arranged to amuse their visitor, by the
Casalis family in those days, and in these, Madame Gentille and her
brother were invariably invited to join. There were gipsy parties to the
woods, drives or rides to some of the queer picturesque out-of the-
world villages, which few of the ordinary visitors to Hivèritz cared to
explore; one delightful day spent up in the mountains at Monsieur
Casalis’s little farm. And despite the sorrows, whose traces could
never be effaced, Cicely found life a happy thing at these times and
felt glad that youth had not yet deserted her. She spoke often of her
mother to Mr. Guildford, and in so doing lost gradually the sense of
loneliness which had so sadly preyed upon her. And she listened
with all her old interest to his account of his own hopes and
ambitions, of the studies and research in which he had been
engaged. But whenever he was speaking of himself or his own work,
a slight hesitation, a somewhat doubtful tone struck her which she
could not explain. One day she learnt the reason of it.
They had gone for a long ramble in the woods—Cicely, Eudoxie,
and two of the Casalis boys, and on their way through the town they
fell in with Mrs. Crichton and her brother, who forthwith volunteered
to accompany them. It was March by now, and quite as hot as was
pleasant for walking.
“It is like English midsummer,” said Cicely, looking up half
longingly into the depth of brilliant blue sky overhead, “only I don’t
think the skies at home are ever quite so blue or the trees and grass
quite so green. The most beautiful English summer day is like to-day
with a veil over it. But I like home best.”
‘Oh! to be in England—’”
“‘Now that April’s there?’”
said Mr. Guildford.
“Yes,” said Cicely.
“Even