Family Practice and Adult Gerontology Primary Care Nurse Practitioner Certification Examination Review Questions and Strategies Print Replica Ebook PDF

Family Practice and Adult Gerontology
Primary Care Nurse Practitioner

Certification Examination Review
Questions and Strategies [Print
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Contributors
Marlene Brennan, DNP, FNP-BC, PMHNP-BC Sandra Ripper-Brown, DNP

Assistant Professor Neuroscience Program
Christine E. Lynn College of Nursing St. Mary’s Medical Center
Boca Raton, Florida West Palm Beach, Florida
Sharon K. Byrne, DrNP, CRNP, NP-C, AOCNP, Denese Sabatino, MSN, ARNP-C, CCRN
CNE Nurse Practitioner/Clinical Educator, Department
Co-Chair, Department of Nursing of Critical Care
Assistant Professor, School of Nursing, Health and Cleveland Clinic
Exercise Science Weston, Florida
The College of New Jersey Baptist Hospital
Ewing, New Jersey Miami, Florida
Denise Vanacore, PhD, CRNP, ANP-BC,

Karin Klause, MSN, FNP-C PMHNP-BC
Florida Community Health Centers, Inc. Director, NP and DNP Programs
Fort Pierce, Florida Gwynedd Mercy University
Gwynedd Valley, Pennsylvania
Gary Laustsen, PhD, FNP-BC, FAANP, FAAN
Assistant Dean, Academic Practice and Innovation Kenneth Winland, MS
Assistant Dean, Practice and Community Engagement Warren, Rhode Island
Associate Professor/FNP
Oregon Health & Science University Karen Wisdom-Chambers, DNP, FNP-BC
School of Nursing Portland Campus Instructor, NP Program
Portland, Oregon Christine E. Lynn College of Nursing
Florida Atlantic University
Donna Maheady, EdD, APRN-BC Boca Raton, Florida
President, www.exceptionalnurse.com
Adjunct Faculty We would also like to thank the following individuals
Utica College for contributions to previous editions:
St. Petersburg, Florida Sandra Allen
Lisa J. Bedard
Denise Coppa
Kymberlee A. Montgomery, DrNP, WHNP-BC, Marcia Gardner
CNE Diane Gerzevitz
Drexel University Allison M. Jedson
College of Nursing and Health Professions Janice S. Hayes
Philadelphia, Pennsylvania Deborah A. Raines
Karen Rugg
Lynne Palma, DNP, FNP-BC, CDE Lorraine M. Schwartz
Associate Professor Susan Elaine Sloan
Christine E. Lynn College of Nursing Douglas H. Sutton
Florida Atlantic University Sharon A. Thrush
Boca Raton, Florida Marcella R. Thompson
vii
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Acknowledgments
We would both like to thank the entire F. A. Davis team, especially Susan
R. Rhyner, Senior Acquisitions Editor, for her vision, enthusiasm, and sup-
port; Marcia L. Kelley, Developmental Editor, for her expertise, efficiency,
and good humor; and Amanda Minutola, Echo Gerhart, Dan Clipner, and
Christine Becker, Editorial and Production Managers, for hanging in there
with us every step of the way!!! Day by Day!
JW-B & LMD
viii
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Contents
UNIT ONE 1
Introduction 1
1. Achieving Success on a Certification Examination 3
LYNNE M. DUNPHY and GARY LAUSTSEN
2. Test-Taking Skills and Designing Your Study Plan for APRN Certification 9
LYNNE M. DUNPHY and GARY LAUSTSEN
UNIT TWO 25
Evaluation and Promotion of Client Wellness 25
3. Health Promotion 27
JILL E. WINLAND-BROWN
4. Care of the Emerging Family 55
DONNA C. MAHEADY and JILL E. WINLAND-BROWN
5. Growth and Development 85
LYNNE M. DUNPHY
6. Health Counseling 117
LYNNE M. DUNPHY
UNIT THREE 155

Assessment and Management of Client Illnesses 155
7. Neurological Problems 157
JILL E. WINLAND-BROWN and SANDRA RIPPER-BROWN
8. Integumentary Problems 183
JILL E. WINLAND-BROWN and KARIN T. KLAUSE
9. Head and Neck Problems 209
KAREN W. CHAMBERS and LYNNE M. DUNPHY
10. Respiratory Problems 239
JILL E. WINLAND-BROWN and KARIN T. KLAUSE
11. Cardiovascular Problems 265
DENESE SABATINO and JILL E. WINLAND-BROWN
12. Abdominal Problems 299
JILL E. WINLAND-BROWN and KENNETH WINLAND
13. Renal Problems 325
JILL E. WINLAND-BROWN and KENNETH WINLAND
14. Male Genitourinary Problems 351
SHARON K. BYRNE and LYNNE M. DUNPHY
15. Female Genitourinary Problems 377
KYMBERLEE A. MONTGOMERY and JILL E. WINLAND-BROWN
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x CONTENTS
16. Musculoskeletal Problems 407

SHARON K. BYRNE and LYNNE M. DUNPHY
17. Endocrine and Metabolic Problems 437
LYNNE PALMA and JILL E. WINLAND-BROWN
18. Hematological and Immune Problems 467
LYNNE M. DUNPHY and JILL E. WINLAND-BROWN
UNIT FOUR 495

Issues in Primary Care 495
19. Issues in Primary Care 497
LYNNE M. DUNPHY and MARLENE BRENNAN
UNIT FIVE 527

Practice Examination 527
Comprehensive Practice Examination 529
JILL E. WINLAND-BROWN and LYNNE M. DUNPHY
4469_Winland-Brown_FM_i-x.indd x 3/21/17 3:04 PM

UNIT ONE
INTRODUCTION
4469_Winland-Brown_Ch01_001-008.indd 1 3/18/17 12:58 PM

Chapter 1: Achieving Success
on a Certification Examination
Certification and Why It Is Important
Licensure
Certification
Your Role
Certification Examinations
American Nurses Credentialing Center
American Academy of Nurse Practitioners Certification
Program
Achieving Success
References
Lynne M. Dunphy
and Gary Laustsen
With the purchase of this book, you have taken a programs, and most states require individuals to main-
major step to achieving or maintaining your certain their RN license to apply for and maintain their
tification as an advanced practice registered nurse APRN license. All but a few states currently require
(APRN). The earlier in your educational process you certification to apply for an APRN license. In addition
begin preparing for the certification examination, the to the states’ requirements of certification for licen-
greater your chance of success. This book will help sure, clinical facilities, employers, and insurance pay-
you understand the certification process and the steps ers require certification.
you need to take to succeed on the certification exam-
ination of your choice.
CERTIFICATION
Certification is the process by which a nongovern-
Certification and Why It Is Important mental agency or association grants recognition to
an individual who has met certain predetermined
There are basic differences between becoming licensed standards for practice. For APRN certification, this
(a process you complete with your state’s board of is achieved through the successful passing of a cer-
nursing or similar entity) and becoming certified. An tification examination. Becoming certified is the
understanding of these differences is important. standard for APRN professionals. As of this writing,
only New York, California, Indiana, and Kansas do
not require certification prior to obtaining licensure
LICENSURE
to practice as a family nurse practitioner (FNP) or
Licensure is a legal requirement of each state to prac- adult-gerontology primary care nurse practitioner
tice nursing in that state. The purpose of licensure is (AGPCNP).
to protect the public from unsafe practitioners. Legal Certification exams, based on an analysis of cur-
regulation of nursing practice (whether at the RN or rent practice, validate entry-level knowledge in an
APRN level) is the joint responsibility of the state leg- advanced nursing specialty in a defined population
islature and the state board of nursing (and in some area. Certification exams are competency-based ex-
states the board of medicine). Registered nurse (RN) aminations that provide a valid and reliable assess-
licensure is a requirement for enrolling in APRN ment of entry-level clinical knowledge and skills of a

4 unit one: INTRODUCTION
APRN REGULATORY MODEL
APRN Specialties
Focus of practice beyond role and population focus linked to health-care needs
Examples include but are not limited to Oncology, Older Adults, Orthopedics, Nephrology, Palliative Care
Population Foci
Licensure occurs at levels
of role & population foci
Family/Individual Women’s Health/ Psychiatric-

Adult-Gerontology Neonatal Pediatrics
Across Life Span Gender-Related Mental Health
APRN roles
Nurse Clinical Nurse Nurse

Anesthetist Nurse-Midwife Practitioner
Specialist
Figure 1-1
nurse practitioner. This certification aligns with the

Box 1-1: Purposes of National Certification
Consensus Model for APRN Regulation: Licensure,
Accreditation, Certification, and Education (LACE). • Required for advanced nursing practice licensure in
Certification exams are administered through testing all but a few states
divisions of professional associations. These include • Indicates specific advanced role and population-
the American Nurses Association (ANA) subsidiary, the based competencies at an entry level building on
foundational nursing knowledge
American Nurses Credentialing Center (ANCC),
• Required for third-party reimbursement in Medicare
and the American Association of Nurse Practitioner’s populations as well as by most other insurers
American Academy of Nurse Practitioners Certifi- • Often required for institutional credentialing
cation Program (AANPCP). National certification • Required by the U.S. Department of Veterans
examinations by these bodies designate an APRN Affairs and the U.S. Armed Forces
role in a specific population (see Fig. 1-1), serve as • Required to obtain a National Provider Identifier
(NPI)
eligibility for licensure to practice in most states, and
are required for most third-party reimbursement, as
well as institutional credentialing. For a list of some
of the main purposes of national certification, review Box 1-2: Recognized Nursing Associations
Box 1-1. and Organizations Offering Advanced-Practice
In summary, the candidate for certification as an Nursing Certification for the Nurse Practitioner
APRN should recognize that certification is a formal Role
process conducted by nongovernmental organizations
to validate entry-level APRN knowledge, skills, and American Academy of Nurse Practitioners Certification
Program (AANPCP): http://www.aanpcert.org
competencies, based on predetermined standards and
practice analysis, and is a part of the requirement in American Nurses Credentialing Center (ANCC):
most states to obtain licensure and status as an APRN. http://www.nursecredentialing.org
See Box 1-2 for recognized certifying organizations for
FNP or AGPCNP practice.
retesting. The purpose of this book is to help you
achieve that goal, but your role in this process requires
YOUR ROLE
a commitment in time and effort to be successful.
You are making an important decision to become Table 1-1 lists the requirements for nurse prac-
an APRN or to maintain your certification through titioner certification by the ANCC and AANP as of

chapter 1: ACHIEVING SUCCESS ON A CERTIFICATION EXAMINATION 5
TABLE 1-1. REQUIREMENTS TO SIT FOR TABLE 1-2. ANCC FAMILY NURSE
NURSE PRACTITIONER CERTIFICATION PRACTITIONER CERTIFICATION
EXAMINATION CONTENT OUTLINE (2016)
ANCC AANP
DOMAINS OF NUMBER OF PERCENT OF
• Present final, • Be a graduate (or imminent PRACTICE QUESTIONS QUESTIONS
degree-conferred graduate) of an accredited
transcripts Master’s NP, post-graduate Foundations for 64 37
• Present validation NP, or DNP program Advanced Practice
of Education • Present official final Professional Practice 30 17
Form signed by transcript with date degree Independent Practice 81 46
program director/ conferred
Total 175 100
faculty • Complete program faculty–
supervised clinical clock
hours
• Hold a current RN license describes the major categories and domains of practice,
as well as related topics and subtopics, which are cov-
ered on the examination. The examination currently
consists of 200 questions, 175 of which are scored and
2015. You must keep abreast of both of these creden- 25 pilot questions that are not scored. The nonscored
tialing Web sites for continued and changing infor- questions cannot be distinguished from the scored
mation regarding the details and processes for taking items.
the certification exam. To qualify to take an examina- The TCO includes information about how the
tion and become certified at the APRN level, a nurse content is weighted—that is, how many or what
must (1) meet the requirements for clinical or func- percentage of the test questions are in each of the
tional practice in a specialized field and (2) provide major domains. Table 1-2 lists the major categories
evidence of successful completion of an approved or domains of practice for the FNP examination and
Master or Doctor of Nursing Practice curriculum. includes an approximate number of questions and
the overall percentage for each category. To facili-
tate understanding of each of the major domains, the
ANCC also includes subcategories in a topical outline
Certification Examinations
format. Table 1-3 provides similar information for the
AGPCNP examination.
This book is geared toward the person who is seeking
The importance of reviewing the current handbook
national certification as an AGPCNP and/or FNP.
and TCO before sitting for the examination cannot be
The AGPCNP certification examination is designed
to assess your abilities as an APRN in the delivery of
primary care services to an adult population, defined as TABLE 1-3. ANCC ADULT-
adolescence through old age. The gerontological nurse GERONTOLOGICAL PRIMARY CARE
practitioner (GNP) certification is no longer offered NURSE PRACTITIONER CERTIFICATION
by either ANCC or AANPCP. EXAMINATION CONTENT OUTLINE (2016)
The FNP certification examination is designed to
assess your abilities as an APRN in the delivery of pri-
mary care services across the life span, including pre- DOMAINS OF NUMBER OF PERCENT OF
and postpartum care, pediatric primary care, and the PRACTICE QUESTIONS QUESTIONS
care of older adults. This spectrum of care is sometimes
referred to as “cradle to grave.” Foundations of 51 29%
Advanced Practice
Nursing
AMERICAN NURSES CREDENTIALING Professional Roles 51 29%
CENTER Independent Practice 73 42%
The ANCC Web site contains the certification hand- Total 175 100%
book, including a test content outline (TCO) that

overstated. All questions are classified according to life an additional 30 minutes for check-in and practice
span and problem-focused content areas. The life span time at the computer, including a tutorial. Because it
dimension for the AGPCNP examination includes is a computerized examination, you will receive your
non–age-specific content as well as specific content score 3 to 5 minutes after completing the examina-
pertaining to the adolescent, the adult, and the aging tion. A passing score is 350 or higher of a possible 500
adult. The FNP life span dimension includes the same points; 2014 statistics reveal 80.5% of AGPCNP and
content as the AGPCNP examination plus content 73.8% of FNP candidates passed on their first attempt.
relating to children, infants, and childbearing women. If not successful, a candidate can apply to retest after
The gerontological population is defined as persons 90 days.
older than age 65. You will need to be recertified every 5 years. At
The last dimension is related to problem areas and present, 500 hours of active practice must be attested
organizes question content by body system—for exam- over the previous 5 years. Additionally, continuing
ple, cardiovascular, endocrine, and respiratory. education credits and/or academic credit must be doc-
What this means is that each test question in the umented. If not able to clinically practice, or if there
Foundations for Advanced Practice and the Indepen- is a lack of continuing education and/or academic
dent Practice domains is characterized across three credit, a practitioner may elect to retake the certifi-
dimensions. For example, a test question that asks cation examination as a way of demonstrating current
about the treatment of a 70-year-old woman with a competency. Please check the ANCC Web site for the
diagnosis of osteoporosis would be characterized as most current information because guidelines for recer-
follows: tification are subject to change.
• Dimension 1—Clinical Management

AMERICAN ACADEMY OF NURSE
• Dimension 2—Life Span: Older Adult PRACTITIONERS CERTIFICATION
• Dimension 3—Problem Area: Musculoskeletal PROGRAM
Be aware that the TCO may change from exam- The AANPCP currently offers competency-based
ination to examination, so you need to review your national certification examinations for the AGPCNP
handbook carefully for the most current content and FNP. Reflecting APRN knowledge and exper-
breakdown. tise, the content areas of these examinations include
To assess each examinee’s level of specialty knowl- health promotion, disease prevention, and diagnosis
edge independent of the group taking the examina- and management of acute and chronic diseases. The
tion, a criterion-referenced standard is used. In this examinations given by the AANPCP were developed
approach, each examinee’s score is compared with an in conjunction with the Professional Examination
absolute number determined by the content experts Service, a not-for-profit organization with more than
who develop the examination. You need to answer 50 years of experience in developing and administer-
every question. Even if you have no idea of the answer, ing national licensing and certification examinations
by sheer chance alone you stand a 25% chance of in health-related fields.
guessing the correct answer. You are not penalized for In order to take either certifying examination,
incorrect answers. candidates must possess a master’s or doctoral degree
The test-development committee determines (DNP) from an accredited program. This certification
the passing score after careful consideration of the program is fully accredited by the National Commis-
content of the test questions. The passing score is sion for Certifying Agencies (NCCA).
always expressed in terms of the number of questions The AANPCP, in conjunction with the Pro-
you must correctly answer on the total test. Diag- fessional Examination Service, conducted a role-
nostic feedback is given if the examinee fails the delineation study to determine areas of clinical
certification exam. Additional statistical examina- knowledge to be tested. As a result of this study,
tion of the pilot questions is assessed for inclusion the examination was structured around assessment
in the final graded pool of test questions on the next (approximately 48 questions, or 36%), diagnosis
examination. (approximately 33 questions, or 24%), formulation/
Your performance on the total test determines planning/implementation of treatment plans (approxi-
your success or failure. The examination is adminis- mately 31 questions, or 23%), evaluation and follow-up
tered year round in a computerized testing center. You (approximately 24 questions, or 17%). The Web site
are permitted 3.5 hours to answer 200 questions. Plan and handbook also provide a list of knowledge areas

chapter 1: ACHIEVING SUCCESS ON A CERTIFICATION EXAMINATION 7
for the FNP and AGPCNP exams. Examinees must be about cultural differences and cross-cultural commu-
able to integrate knowledge of pathophysiology, psy- nication, will be integrated with content concerning
chology, and sociology with the assessment, diagnosis, specific aspects of diagnosis, pharmacology, and dis-
and treatment of patients in primary care. Knowledge ease management.
of health promotion and disease prevention, as well as Questions testing physical assessment and
management of acute/episodic and chronic illness in history-taking skills, as well as content from advanced
the primary care setting, are tested. physical assessment, remain prominent. Although a
The AGPCNP examination tests knowledge of certain amount of basic pharmacological content is
adolescent, adult, and geriatric primary care; the FNP included, the latest drugs and pharmacological inter-
examination tests clinical knowledge of prenatal, ventions may not always appear because the examina-
pediatric, adolescent, adult, and geriatric primary care. tion questions are prepared and tested well in advance.
These examinations use growth and development (Note: Questions about your knowledge of safe pre-
as the basis of age-related changes, and specific age scribing for pregnant women almost always appear on
parameters are not defined for any population. the FNP examinations.)
These AANPCP examinations have a pass rate Be careful in applying your experiences from
of 87.5% for FNP and 85.7% for AGPCNP according clinical activities as a student or as a newly certi-
to 2014 data. They are also computer-based examina- fying APRN. The correct answer and other answer
tions offered year round. You know whether you have choices—also referred to as “distractors”—will not
passed or failed at the end of the examination. necessarily correlate with what you’ve currently seen.
Remember, the examination reflects the ideal answer
according to the references used and the expert pan-
Achieving Success els of the certifying body; this ideal answer may not
always mirror the realities of specific practices. Test
Nurse practitioner programs often focus on assess- answers are drawn from national guidelines and stan-
ment, management, and evaluation of disease. Indeed, dards of practice promulgated by a variety of bodies.
this is the role most of you perform in your respec- New national guidelines or standards may take up to a
tive work settings. The ability to diagnose and treat year for questions to be developed, piloted, and then
disease is paramount to your safe and effective func- included in the exam. The questions on the examina-
tioning as an APRN, and certification examinations tion are looking for generalized responses and might
increasingly reflect this reality. However, it is import- well reflect phenomena that you have not seen. Allow-
ant never to lose sight of the fact that these exam- ing yourself to become frustrated with the distractors
inations are certifying your abilities as an APRN and will not help you but rather will hinder your ability to
as such have an underlying commitment rooted in succeed. This is why it is essential that you study large
nursing-based knowledge, health, health promotion, numbers of sample test items (see chapter 2).
and human responses to health and illness. This is Being test savvy and succeeding on a multi-
especially apparent on the TCO of the ANCC example-choice examination is a far different skill from the
ination. Fully 37% of content is labeled “Foundations expert skills you bring to your practice. These skills
of Advanced Practice.” are not mutually exclusive. It is a matter of having the
As an APRN, your reaction to the various correct mind-set—one predicated on an awareness of
manifestations of health and illness phenomena is the nursing base of the certification examination cou-
instinctively different from that of other primary pled with an understanding of the test blueprint. Be
care providers. This comes up in different ways on determined not to select an anecdotal answer based
each examination, but it is an important distinction on experience from your practice experiences but
to keep in mind as you ponder the various ques- rather to select an answer based on nationally recog-
tion responses and wonder what answer is the best. nized, clinically based guidelines and rooted in clinical
Similarly, the test blueprints and types of questions literature.
asked reflect a continued commitment to concepts of You have taken the first step toward certification
health promotion and disease prevention as well as by purchasing this book. Understand the essential
to the underlying principles of therapeutic commu- reasons to become nationally certified. Fix the end
nication skills that are so essential to forging mean- goal vividly in your mind. Imagine how you will feel
ingful APRN-client relationships. Nursing-based when you receive that message on the screen saying
elements of growth and development, nutrition, and PASS, knowing that you are a nationally certified
therapeutic communication, as well as questions APRN.

Take the next step on the road to success by American Academy of Nurse Practitioners Certifi-
turning to chapter 2. It will assist you in the devel- cation Program description: http://www.aanp.org/
opment of important test-taking skills and pro- education/aanp-certification-program
vide guidelines for creating your individualized American Nurses Credentialing Center certification
study plan. Web page: http://www.nursecredentialing.org.
Dunphy, LM, Winland-Brown, JE, Porter, BO, and
References Thomas, D: Primary Care: The Art and Science of
Advanced Practice Nursing, ed 4. FA Davis, Phila-
Advanced Practice Registered Nurse Consensus delphia, 2015.
Model for Regulation: http://www.nonpf.org/default National Organization of Nurse Practitioner Faculties:
.asp?page=26 http://www.nonpf.com/

Chapter 2: Test-Taking Skills and
Designing Your Study Plan for APRN
Certification
Study Habits: Know Yourself
What Is Your Preferred Learning Style?
Active Versus Passive Studying
Getting Started
Tips for Studying
Nature of the Exams

Test-Taking Skills: An Acquired Art
General Strategies
Basic Tools
Specific Strategies
Designing Your Study Plan

Assess and Diagnose
Plan and Implement
Evaluate
Last-Minute Preparations: Relaxed and Ready

References
Lynne M. Dunphy
and Gary Laustsen
This chapter has several parts. The first part actively

assists you in assessing your study and testing style. It Study Habits: Know Yourself
prepares you to develop an individualized study plan
that will enable you to achieve your goal: becoming a There are several approaches to developing good study
nationally certified advanced-practice registered nurse habits and effective test-taking skills. Among them are
(APRN). Another part reviews the nature of the adult- recognizing what your preferred learning style is, real-
gerontology primary care nurse practitioner and family izing the importance of active versus passive studying,
nurse practitioner certification examinations (we use the and following basic tips for getting started and devel-
term “exam” from this point on) and how that translates oping test-taking skills.
to actual test questions. The remaining parts deal with
the specifics of answering multiple-choice test questions WHAT IS YOUR PREFERRED
and the skills necessary to succeed on a multiple-choice
LEARNING STYLE?
exam. Evaluating test-taking skills, developing a for-
mal study plan, and being ready on exam day are also Awareness of your learning style will guide you in
covered. selecting study strategies. Learning styles are related

to the pathways or channels through which you pre- channel. Think about which of the three learning styles
fer to absorb information. The three types of learners discussed works best for you. Time is often at a premium
are commonly identified as visual, auditory, and tactile for nurses studying for certification, and capitalizing on
(sometimes called kinesthetic). your preferred learning style will help you study in the
most efficient way. Keep strategies for your preferred
Visual Learners learning style in mind as you develop your study plan.
Visual learners learn better from reading and writing

than from hearing and talking about information. ACTIVE VERSUS PASSIVE STUDYING
They usually find background noise, such as music and Regardless of your personal learning style, the more
television, distracting rather than helpful. Following actively you are engaged in the material, the better
are strategies for visual learners: your ability to retain and comprehend content. For
• Read texts in a quiet place. example, many of us have had the experience of read-
ing an entire chapter, or listening to a review CD, only
• Watch appropriate videos.
to find that our mind drifted away sometime earlier
• Use visual study aids such as concept maps, and we have difficulty recalling even the most basic
flash cards, and charts. information. Time is a precious commodity, so it is far
• Use highlighting markers or colored paper to more efficient to learn actively the first time than to
take notes. reread or relisten to an entire chapter a second time.
Tips used to improve active learning include taking
Auditory Learners notes while reading and pausing after each heading or
subheading to summarize the content. Can you iden-
Auditory learners grasp information most effectively tify the main idea that the author was attempting to
by listening and talking. Combining information with impart? Did you pass over new terms without taking
music often works well for auditory learners. Following the time to become familiar with them? As you read a
are strategies for auditory learners: summary, do you realize that you really need to go back
• Read texts aloud. to a more detailed reference because your knowledge
is insufficient? Although active engagement may slow
• Listen to audiotapes of course material. you down initially, it will save you time in the long
• Make up a song about the content and sing run because now you are involved in active learning
it aloud (especially helpful for assimilating and not simply hoping that something will stick as you
difficult content). speed by.
• Listen to background music or other noise.
• Talk about the content with a study partner. GETTING STARTED
Studying, like regular exercise, is good for the brain.
Tactile or Kinesthetic Learners As a health-care professional, you will find that it will
Tactile or kinesthetic learners prefer to learn “hands always be your job to keep abreast of the professional
on.” They have difficulty sitting still for long periods. literature and spend some time studying. To recer-
During study sessions, they should stand and move tify, you are mandated to keep your practice current
around or take frequent stretch breaks. Integrating through a combination of clinical hours and continu-
physical activity with study works well for these learning education options. The earlier you begin to plan
ers. Following are strategies for tactile learners: for certification or recertification, the better.
The principles of effective study are simple—
• Move around while studying. worthwhile studying takes time and effort. And in
• Read while exercising on a stationary bicycle. today’s world, time is a precious commodity. There-
• Listen to tapes of learning material while fore, if you want to study, you need to set aside ade-
walking or biking. quate time and plan accordingly. Be prepared to delay
the start of new projects until this one is complete and
• Rewrite or type notes.
you have successfully taken the exam. There is no way
Although almost everyone is capable of learning around the hours involved. There are no shortcuts.
through all their sensory pathways, most have a preferred But you need to make it easy to begin.

chapter 2: TEST-TAKING SKILLS AND DESIGNING YOUR STUDY PLAN FOR APRN CERTIFICATION 11
TIPS FOR STUDYING preferable. Study for short periods with frequent
breaks.
Just as a cold engine will run a little rough, settling
down to study when one is out of the habit can be dif- • Integrate whatever learning modalities
ficult. The following suggestions should make it easier work best for you. For example, if you are an
to begin studying and to return to it on a regular and auditory learner, use recordings. Listening to
consistent basis. recordings while you are walking is especially
good for tactile learners.
• Create a pleasant personal environment. • Think in terms of “bite-size” pieces and
This is a very basic but frequently overlooked structure your study plan accordingly. Use the
requirement for successful study. Organize “salami” principle: Cut large tasks into smaller
all your study materials in one area. Try to ones and digest them one at a time. This will
create a pleasant and regular work space for keep you from becoming overwhelmed and
yourself. Perhaps it will be just part of a room, defeated before you begin.
but make it an inviting part. Decorate it with
• Variety is essential. For example, divide
flowers, pictures, or whatever makes the area
your time between test question review and
appealing to you. For the kinesthetic learner,
content review, or break up the study period
an open area that allows free movement may
into a variety of different tasks. Take notes for
be better than a small office. Some literature
part of the time and read for part of the time.
suggests that playing classical music, especially
Do not keep at any one activity—even your
from the baroque era, in the background
practice exams—for longer than 45 minutes.
increases concentration and retention. Decide
Try studying with a study group part of the
whether background music is helpful for you or
time. Discussing the materials with others is an
distracting. Background music may be helpful
especially good strategy for auditory learners.
for an auditory learner, whereas a visual learner
Although a 45-minute session is ideal for most
may find it a distraction.
of your study time and for taking practice
• Plan your activities in advance and be exams, it is helpful to experience at least one
realistic. Plan in advance what you are going to practice exam with many questions (~150) to
work on and do not be overly ambitious. Blocks get a sense of what it will be like when you take
of 1 hour at most are recommended, with a the actual certification exam.
10-minute break every 45 minutes. List the
• Study with your purpose in mind—in this
tasks beforehand; otherwise, you might spend
case, passing the certification exam. Research
valuable time trying to decide what material
has shown that two-thirds of your study time
to review. Set specific targets for the time
will be most effectively spent taking sample test
available.
questions. Do not lose sight of this! Studying
• Keep focused on the goal: becoming certified! does not necessarily mean sitting and reading
Keep the benefits of studying clearly in mind—in textbooks. Reading books in a linear fashion
this case, the joy of receiving your passing score, is often not the most effective way to master
followed by your embossed certificate in the information. Always keep the end result in
mail. Visualize and imagine what it will feel like mind.
when you read the word PASS on the computer. • Leave the environment in readiness for your
Picture the certificate framed and hanging in next session. Leave your work environment
your office. Focus on these results and how they inviting for the next time. Put your materials
make you feel. Close your eyes and allow the away so that they are easily accessible. Do not
feelings to flood through you! leave the area cluttered; instead, make it more
• Use your knowledge of yourself and of basic pleasing. Spend the last few minutes of your
tips. There are a number of ways you can study time tidying up so that your environment
make studying more fun. Make use of your best is all set for your next session. This is also an
time of day. For some, this might mean rising excellent time to plan what you will do the
early while the rest of the household sleeps next time you sit down to study. Believe it or
and stealing time alone, undisturbed, with a not, these small, concrete habits can make a big
hot cup of tea or coffee. For others, evening is dent in your natural tendency to procrastinate.

• Reward yourself. Last but not least, reward Plan time to familiarize yourself with the technol-
yourself! Reward yourself for each study period. ogy before the exam begins. There are simple tutorials
You might decide that if you spend 3 hours to “warm you up,” helping you feel more comfortable
studying on Saturday, you will see a movie with the computerized format before beginning the
on Saturday evening or go to the mall or actual exam questions.
treat yourself to a special activity! Be good to
yourself.
Now that you understand yourself better and know Test-Taking Skills: An Acquired Art
how to approach studying for the exam, we move on
to providing some specific information about the cer- The ability to select the best response to each question
tification exams. is what determines your success on the exam. Knowl-
edge of the content is, unfortunately, not enough to
guarantee success. If you are not able to communicate
your knowledge through the medium of the exam, you
Nature of the Exams will not succeed in becoming certified. Succeeding on
a certification exam is not always indicative of your
The ANCC exam consists of 175 scored questions and actual practice ability or intellectual capability.
25 items being piloted that do not count in your score.
The AANP certification exams consist of 150 scored
multiple-choice questions, 15 of which are pilot ques- GENERAL TEST-TAKING STRATEGIES
tions. The exam is administered on a computer at a
Some general principles apply to preparing for and
testing center, and you will know within a few minutes
taking any sort of standardized test, regardless of the
after you complete the exam if you have passed. The
content area. Familiarize yourself with these strategies
questions are at a variety of difficulty levels, adminis-
listed in Box 2-1.
tered in an integrated format. The exams are not com-
puter adaptive at this time. Computer-adaptive testing
is the technique used for the NCLEX-RN licensure
exam. With computer-adaptive tests, each answer, Box 2-1: General Strategies
correct or incorrect, determines the difficulty level of
the next question a participant receives, and each par- • Avoid changing answers.
• Develop a self-confidence mantra to recite if you
ticipant may answer a different number of questions to find yourself doubting your knowledge.
meet a minimum passing level. • Develop and stick to a study plan; avoid last-minute
The AANPCP exam as of this writing is com- cramming.
posed of multiple-choice questions only. The ANCC • Do not linger too long over one question.
exam includes four types of questions: (1) multiple • Focus on concepts, not details, during study
periods.
choice, (2) multiple response, (3) drag and drop, and
• Focus on decreasing your test-taking time.
(4) hot spot. Most of the test questions are multiple • Maintain objectivity; avoid adding your own
choice. If you are planning to take the ANCC exam, interpretation.
it would be helpful to review on the ANCC Web • Read all answer options.
site examples of the alternative type questions. This • Read questions as though you are speaking them
format means that you must be able to identify key aloud in your head to avoid scanning.
• Time yourself in practice tests; allow 45 to 60
words or phrases on a computer screen, not on the seconds for each question.
traditional paper format. Many test takers feel con- • Use concept maps.
strained when they are unable to underline or high- • Use practice tests to increase confidence.
light key words and phrases. A helpful tip: Use the • Work on self-confidence.
scratch paper and pencil provided to you when taking
Source: Adapted from Sides, MB, and Korchek, N:
a computer-based exam to write down the key phrases Successful Test-Taking Strategies, ed 3, Lippincott Williams
if that helps you focus on the topic and/or issue being & Wilkins, Philadelphia, 1998, p. 77; and Dickenson-Hazard,
presented in the question. Remember that the scratch N: Test-taking strategies and techniques. In Kopac, CA,
and Millonig, VL (Eds), Gerontological Nursing Certification
paper is collected by the testing center staff before you Review Guide, revised ed, Health Leadership Associates,
may leave the testing area; this is done to maintain Potomac, MD, 1996, pp. 3–5.
test question security.

Achieving success on a multiple-choice test is a skill; you with a choice between assessment and implemen-
and like any other skill, it can be improved. Remember tation, you should remember these basic tips. The
how you improve other skills, such as playing an instru- purpose of assessment is to validate or confirm the
ment or a sport: practice. The same holds true for test- problem. When considering an answer choice that
taking skills. The best way to succeed on the exam is is an assessment, you should ask yourself, “Is this
through practice, practice, and more practice. an assessment that is appropriate to the topic of the
The more you practice answering sample test ques- question?” If it is, you should carefully consider this as
tions, the better you will become at it. That is why a very likely answer choice. If, however, you believe
we have written this book for you. This book provides the correct answer choice is an implementation, you
over 2,000 sample test questions. Research has shown should ask yourself, “Do I have enough information
that two-thirds of study time should be spent taking to implement what the answer choice is asking me
sample tests, and one-third of the time should be spent to do?” Last, if the answer choice is asking you to
reviewing content. A number of exam-preparation evaluate a situation, you should ask yourself, “What
books are available to you; however, very few contain would be the outcome if I choose this answer?” The
nearly the number of test questions you need to develop criteria for reference are always your textbook and/or
and flex your test-taking muscles. This book provides professional guidelines, and you should avoid answer
enough questions to enable you to do that. Addition- choices that are too narrow or reflective of an indi-
ally, reading through the answers in the rationales— vidual practice preference. Each exam publishes a set
the why of the reason the selected answer is correct or of textbook references that are used in the creation
incorrect—is an excellent way to expand your knowl- of the exam questions. It is a good practice to review
edge base in general. It also provides insight into how this list of text references.
answers are keyed—why one answer is rated as correct
over another answer that seems to make more sense
Maslow’s Hierarchy of Needs
to you. Remember: You will not be able to argue with
the certifying exam creators as to your theory about Another important tool is Maslow’s hierarchy of needs.
why one answer is “more correct.” Allow yourself to It is particularly helpful in making priority decisions.
“tune in” to these rationales so that you become more According to Maslow, there are five levels of human
familiar with the answers that are noted to be correct. needs: physiological needs, a need for safety and secu-
In addition to the general strategies for test taking rity, a need for love and a sense of belonging, a need for
listed earlier, there are specific tools and strategies to self-esteem, and a need for self-actualization. Because
strengthen the test-taking skills you will need for certi- survival is grounded in basic physiological needs, these
fication. We will review two nursing tools and give you needs take priority over any other human needs. It
some specific strategies for how to use them in testing comes down to practicality: If you do not have oxygen
situations. to breathe or food to eat, your focus is not really on the
stability of your love life. When trying to determine
the priority between a physiological need of a client
BASIC TOOLS
versus a psychosocial need, remember the priority is
Two basic tools that are used in nursing—and that you to meet the physical needs of the client. This doesn’t
should employ when taking the certification exam—are imply that the correct answer is never psychosocial; it
the nursing process and Maslow’s hierarchy of needs. simply means that survival of the species requires us
to address physiological needs first, before we advance
through the other stages of human needs. Always
The Nursing Process
think ABCs—Airway, Breathing, Circulation. Care-
The nursing process is a great tool when taking your fully evaluate each item and ask yourself “What level
certification exam because it can guide you through of need is the question addressing? Physiological? Need
problem-solving. The AANP certification exam for self-esteem?”
structures very specific pieces of information around
these areas (see the table of contents on the Web
SPECIFIC STRATEGIES
site). As you recall from your basic nursing educa-
tion program, the steps of the nursing process include The following specific strategies should help in
assessment, diagnosis, planning, implementation, answering the multiple-choice questions on the cer-
and evaluation (ADPIE). When a question provides tification exam.

Strategy #1: Understand and Analyze the is in the form of an incomplete statement, is in bold
Anatomy of a Test Question print.
A multiple-choice test question consists of three parts: EXAMPLE 1
• An introductory statement, which sets up the A 32-year-old woman comes to your office for a routine
clinical scenario examination. Her blood pressure is 116/74. You should
• A stem, which poses a question or incomplete recommend that the client have her blood pressure checked
sentence again in
• Options, from which you must select the correct
A. 6 months.
answer
B. 1 year.
The first step in analyzing a multiple-choice test
C. 2 years.
question is to separate what the question tells you from
what it asks you. The introductory statement, which D. 5 years.
may vary considerably in length, provides informa-
tion about a clinical scenario, a disease process, or a The first and most important step is to identify what
nursing response. The stem poses a specific question, the question is asking. You cannot expect to answer the
which you must answer on the basis of your advanced- question correctly until you understand the topic of
practice nursing knowledge. Stems are worded in dif- the question. The introductory statement of Example
ferent ways but always contain enough information to 1 gives you information about the clinical situation—a
answer the question. Some stems are in the form of 32-year-old female client came to your office for a rou-
a question; others are in the form of an incomplete tine exam and has a normal blood pressure; these are
statement that you must complete. You must then the topics. The stem asks you for a clinical judgment
select the one option that best answers the question based on your knowledge of clinical guidelines—when
or completes the incomplete statement from a num- should she have her blood pressure checked again? You
ber, usually four, of potential options, sometimes called must select the option that provides the most accurate
distractors. response—in this case, option C is correct according
Here are a few additional considerations in under- to current guidelines. This question is an example of
standing the format of questions: a recall (memory-based) question, sometimes called
a knowledge-based question. You need to know and
1. Answer options on certification exams will recall the guidelines concerning the frequency of blood
not include “All of the above” or “None of the pressure measurements under different circumstances
above.” and within different populations.
2. Answer options often have very similar Other test questions assess comprehension.
wording with only a few of the words or This is defined as “drawing inferences from informa-
phrases distinguishing the correct answer from tion without necessarily relating inferences to other
the incorrect options. material”—in other words, using only the information
3. Questions are not phrased “negatively.” That that is present in the question. Test takers often fall
means you will not have to choose an answer in into the trap of “reading into” these types of questions—
which the correct response is not to do something. thinking about information that is not requested in the
question.
4. Abbreviations (except a few standard ones) are
always spelled out. EXAMPLE 2
5. There are no fill-in-the-blank questions.
A 41-year-old man comes to your office complaining of
6. Generic drug names are used with some trade having hit his head. While assessing his eyes, you note that
names appearing in parentheses after the the left pupil constricts simultaneously when the right pupil
generic name. Don’t learn just trade names. receives direct light. His left pupil exhibits which reaction?
Knowing these components will assist you in ana- A. Direct papillary reaction
lyzing the information presented and in focusing on
B. Consensual papillary reaction
the question’s intent or issue. Let’s look at an example
that includes an introductory statement in the form of C. Convergence reaction
a clinical scenario. The stem, which in this example D. Corneal light reflex reaction

In this case, the correct answer is option B. You Strategy #2: Identify the Questions, Critical
were able to comprehend the requested information Elements, and Key Words
based on the exact information given in the question.
Nursing, however, is a practice-based discipline. The ability to identify the critical elements and key
Nurses must apply knowledge to specific situations. words in a test question is crucial to a correct inter-
This ability is assessed through the application ques- pretation of the question. Critical elements, such as
tions designed to assess your ability to implement, the key concepts and conditions, tend to appear in
solve a problem, or perform a task. Application of the introductory statement, whereas key words usually
nursing knowledge is essential to safe, competency- appear in the stem of the question. Regardless of the
based, entry-level advanced nursing practice. Appli- placement of these words, remember that everything
cation sometimes implies analysis of information, you need to be able to answer this question correctly is
meaning the question requires you to dissect and ana- provided for you.
lyze information and/or distinguish between relevant Key words are important words or phrases that
and irrelevant data. The certification exam is a test help focus your attention on what the question is spe-
of “minimum competency,” and simply recalling facts cifically asking. Examples of key words include most,
would not provide the certification bodies with suffi- first response, earliest, priority, on the first visit, on a sub-
cient information to determine your abilities. As such, sequent visit, common, best, least, immediately, and ini-
you can expect the majority (up to 75%) of questions tial. Take a look at this example.
to be application and analysis type questions. These
require you to integrate knowledge with the facts that EXAMPLE 4
are presented in order to choose the single best answer Which of the following is an example of a primary preven-
for each question. Review the following example. tive intervention?
EXAMPLE 3 A. Blood pressure screening
Julie, age 18 months, is up to date with her immunizations B. Pap smear
and is due to receive her diphtheria, tetanus, and acellular C. Screening sigmoidoscopy
pertussis (DTaP) and polio vaccinations today. Her father D. Tetanus prophylaxis
is bedridden at home with AIDS. Which immunizations
should Julie receive today? Example 4 is a recall question with a positive-
response stem. Although all the interventions are
A. DTaP only
preventive, the key word is primary, allowing you to
B. DTaP and inactivated polio vaccine (IPV) choose the correct answer, option D.
C. DTaP; IPV; and measles, mumps, and rubella After identifying the topic of the question, you
(MMR) must also identify the issue the question is asking
D. DTaP, OPV (oral polio vaccine), and MMR about. For example, the question, as in Example 5,
may be requesting information about a disorder.
You must synthesize several concepts regarding
immunizations to select the correct answer (option B) EXAMPLE 5
for this question. You must integrate your recall knowl-
Mr. Williams, age 76, is seen in the ambulatory care clinic.
edge regarding standard and current immunization
He is complaining about incontinence, suprapubic pain,
schedules (e.g., that Julie should receive DTaP and
urgency, and dysuria. A urinalysis reveals the presence of
polio immunizations on this visit) with the specific
white blood cells (WBCs), red blood cells (RBCs), and
clinical scenario.
bacteria. What is your diagnosis?
A common error test takers make in a multiple-
choice testing format is to analyze the question and A. Pyelonephritis
choose the answer with their eyes. Analysis is, how-
B. Nephrotic syndrome
ever, done with the brain. Be careful of choices that
“look good.” The reference for every correct answer C. Benign prostatic hypertrophy (BPH)
is grounded in textbook and/or professional guideline D. Cystitis
knowledge. A common trap that test question writers
use is to include answer choices that appear on the sur- By selecting the correct answer, option D, you
face to be correct but are not. have demonstrated knowledge related to a disease

process, the issue about which this question requested and states, “I’m afraid of having a mammogram.” Your
information. Other examples of issues include drugs, initial response is
such as antibiotics or immunizations; diagnostic tests,
such as urinalysis or serum glucose; toxic effects of A. “You must have the mammogram.”
a drug, such as rash or vomiting; problems, such as B. “Don’t worry; I’m sure it is nothing.”
knowledge deficit or substance abuse; procedures, C. “Wonderful advances have been made in breast
such as bone marrow aspiration or cardiac catheter- cancer research.”
ization; behaviors, such as agitation or overeating;
D. “You’re feeling scared?”
and, occasionally, a combination of these. Consider
this example.
The correct answer is option D. This example of
therapeutic communication acknowledges the cli-
EXAMPLE 6
ent’s fear and encourages her to verbalize her feelings.
Which drug is used in the treatment of acute gout? Table 2-1 reviews communication techniques that
facilitate therapeutic communication and those that
A. An NSAID (e.g., indomethacin) block therapeutic communication.
B. A xanthine oxidase inhibitor (e.g., allopurinol) Another important component in selecting the
C. An antibiotic (e.g., cephalexin) correct answer to questions that address your ability
to communicate therapeutically is prioritization of
D. A topical numbing agent (e.g., lidocaine spray)
responses. More than one option may contain a ther-
This is a recall/knowledge-based question based apeutic response. But which is the first, best, or most
on your understanding of the pharmacological treat- therapeutic response in that situation? Communica-
ment options for an acute disease. The correct answer tion theory emphasizes that it is a priority to address
is option A. the client’s feelings first. Validate, validate, validate.
“You seem to be very sad today, Mr. George.” “I can
see that you are upset.” “You seem very anxious, Mrs.
Strategy #3: Use Therapeutic Smith.” This should always be done before clarifying
Communication or presenting information. Is there a need to address
the feelings? If so, this takes priority. Empathy, restate-
In communication-type questions, you are always look-
ment, reflection, and being silent, as well as remain-
ing for a therapeutic response, the cornerstone of the
ing with the client are all excellent nursing strategies
nurse-client relationship. To communicate therapeuti-
that can potentially validate client’s feelings. The only
cally, you need to use communication tools and avoid
exception to this rule would be the presence of a press-
communication blocks. Remember your basic thera-
ing or interfering physical problem.
peutic nursing role. The nurse, whether at a generalist
or advanced-practice level, is always therapeutic. Your
role is not that of an authority figure. This may cause Strategy #4: Identify the Person Who Is the
some confusion for practitioners from other cultures Focus of the Question
in which health-care providers are conceptualized as
authority figures who give directions. Remember, this Another critical element is your ability to identify the
is a nursing-based exam. Your initial response is always person who is the focus of the question. This person
the therapeutic response—the acknowledgment and might be the client who has the health-care prob-
validation of the client’s feelings. This is really a safety lem, a family member or neighbor of the person with
issue. Are your responses to clients and families safe? the health-care problem, or another member of the
In acknowledgment of the importance of this aspect health-care team. Take a look at this example.
of advanced nursing practice, therapeutic communica-
tion and the nurse-client relationship are included in EXAMPLE 8
the ANCC and AANP test content outlines and are
Mr. Boyd, age 84, has dementia and is being evaluated in
critical aspects of all nursing practice.
a long-term care facility. His daughter and son-in-law are
visiting. As they get ready to leave and begin to say good-
EXAMPLE 7
bye, Mr. Boyd grabs his daughter’s arm and begins to cry,
Ms. Dortney, age 55, is very fearful because of a breast saying, “Don’t leave me here. I will die in this place.” As
lump the NP has just identified. The patient begins to cry she leaves the room, his daughter is visibly upset and asks

TABLE 2-1. COMMUNICATION TECHNIQUES
TECHNIQUES THAT FACILITATE THERAPEUTIC COMMUNICATION
Techniques Examples
Offering self “I’ll stay with you.”
Showing empathy “I see you are upset.”
Silence Remaining present but silent
Giving information “You need to take this drug two times a day.”
Restatement “You feel hurt?”
Clarification “You are saying that …”
Reflection “You seem to be anxious.”
TECHNIQUES THAT BLOCK THERAPEUTIC COMMUNICATION
Techniques Examples
False reassurance “Everything will be OK.”
Disapproval “That was wrong.”
Approval “That was right.”
Requesting an explanation “Why did you do that?”
Giving advice “I think you should …”
Deferring “You need to talk with your doctor about that.”
Defensiveness “We are understaffed!”
Devaluing feelings “That’s silly; don’t be upset!”
the NP if she should visit again soon because it has upset Strategy #5: Determine the Best Response
her father. The best reply for you to make is
There may be more than one option in a test question
A. “You might try telephoning next time instead that is correct. But which is the best, first, or most
of visiting. Your father will know that you are therapeutically sound response to the question posed?
thinking of him then.” Application/analysis-based test questions often involve
B. “I will give you the number of the social worker. decision making, which is based on prioritization.
She will be able to arrange a team conference and Therapeutic communication skills teach the acknowl-
family meeting.” edgment of feelings first. Teaching and learning theory
C. “This is a very upsetting time for all of you. reminds us that unless the client is motivated to learn,
However, it is important that you continue to no client teaching will be successful. If the client is not
visit regularly. For now, I will go in and sit with motivated, this issue must be addressed first.
your father for a little while.” To assist you in the correct answer selection, use
the following tips:
D. “He needs time to adjust to this new setting.
Perhaps it might be easier on you all if you just • Assessment always comes before diagnosis and
didn’t visit for a few days.” treatment.
In this question, the person who is the focus of the • The key word initial usually implies the need to
question is Mr. Boyd’s daughter, not Mr. Boyd. The key prioritize.
word in the stem is best reply. It is also helpful to iden-
• Remember Maslow’s hierarchy of needs.
tify the issue the question is asking about. The issue in
this question is one of therapeutic communication— • In communication-based questions, you must
specifically, Mr. Boyd’s daughter’s feelings of concern address the client’s feelings first.
about her father. Option C is the correct response • In teaching and learning situations, learning is
because it validates the daughter’s feelings first. contingent upon motivation.

As stated earlier, according to Maslow, physio- your exam. You have answered a few questions easily,
logical needs always come first. In determining which but now you have come to a test question to which you
physiological needs have priority, you might recall do not know the answer. You have identified the intro-
the ABCs for basic cardiopulmonary support—A for ductory statement and the stem and have read through
airway, B for breathing, and C for circulation. This is the options. You have identified the issue and the person
handy to remember for questions that present a sudden who is the focus of the question. But you are still uncer-
emergency situation or any situation that is potentially tain of the answer. If this happens, follow these tips:
life threatening for the client. Once basic physiologi-
• Eliminate incorrect options. This is very
cal needs are met, safety is the next priority, followed
important. Frequently, you will be able to
by psychosocial needs.
eliminate two choices easily. If even a small
part of the answer choice is incorrect, the
Strategy #6: Avoid Common Pitfalls whole answer choice is incorrect, and you
must eliminate it from further consideration.
A very common cause of test-taking errors is misread-
Eliminating incorrect answer choices improves
ing the test question. To avoid common pitfalls, follow
your chances of choosing the correct response
these tips:
even when you are unsure of the exact answer
• Ask yourself, “What is this question really choice. The key is to not panic. It is not
asking?” realistic to expect to know everything that
• Look for the key words. you will be tested on, but through careful
preparation, use of test-taking tools and
• Restate the question in your own words. strategies, and analysis of the content presented
Eliminate any options that require you to make in the question, you will improve your chances
assumptions about information that is not of successfully answering the question and
presented in the case scenario and any options passing the certification exam on the first
that contain information not presented in attempt—a noteworthy goal!
the scenario. Do not read anything new into or
overanalyze the test question! Go with your first, • Select the most global response option. The
most straightforward response. It is usually your option that offers the most comprehensive or
best bet for answering the test question correctly. general statement is often a better answer than
an option that is more specific and thus more
• Carefully review the question using the limited.
systematic format and strategies suggested in
this book. • Eliminate similar options. If two options say
essentially the same thing, neither can be correct.
• Make a decision about each option as you If three of the four options sound similar, the
read it; this is an efficient approach to test “odd” one should win out. In other words, look
taking. Do not go back to that option once for patterns or relationships within the answer
you have eliminated it, do not overcomplicate choices to help you select the best answer.
the case scenario presented, and do not rely
on anecdotal data from your own practice. • Look for words or phrases in the option
These are national exams with testing content that are similar to those in the introductory
based on national standards of practice and
commonly used textbook references.
• After choosing an option, read the selected Box 2-2: Key Test-Taking Tips
response “back into the question.” This will
• Eliminate options you know are incorrect. If you
help clarify whether the selected response
can eliminate two options, even a guess has a 50%
makes sense in the context of the question. chance of being correct.
• Answer all questions as if the situations were ideal.
• Read the test question carefully.
Strategy #7: Select the Best Answer When • Separate what the question tells you from what it is
You Do Not Know the Answer asking.
• Select the most global response.
We now discuss some more specific strategies for select- • Be alert to information relevant to answering the
ing the best answer. Certification exams do not penal- question in the stem or in earlier questions.
ize you for guessing. Imagine that you are beginning

statement or stem. Try this strategy if you need the questions you did. Failure to analyze why you
to guess. missed a specific question is a commonly missed
• Be alert to relevant information from earlier opportunity to improve your skills. Simply comparing
questions. your answer choice to the correct answer choice is a
passive learning process. However, analyzing why you
To summarize, key test-taking tips are given in missed a question (assessment) and actively creating
Box 2-2. a strategy to correct the knowledge or skills deficit
(implementation) will help you achieve the outcome
you are seeking. For example, did you miss the cor-
Designing Your Study Plan rect answer because you did not know or remember
the content? This is a knowledge deficit. Or did you
In creating your individual study plan, review and miss a key word, read too much into the test question,
apply the phases of the nursing process: assess, diag- or change your answer? If so, you need to continue
nose, plan, implement, and evaluate. to work on test-taking skills. You must become pro-
ficient at both—content knowledge and test-taking
skills. Recognizing where you are vulnerable and then
ASSESS AND DIAGNOSE
taking steps to improve in that area gives you a sig-
Begin by taking some sample exams. You might first try nificant edge in preparing for your exam and building
taking one of the practice exams that are in the back of your confidence. These objectives are best achieved
this book. Do only 150 questions and then assess your through ongoing self-testing with sample exam ques-
score. This will give you an idea of your baseline and how tions such as the ones provided for you in this book.
intensive your study plan needs to be. Then, move on to Evaluate what percentage of questions you missed
the specific content areas in this book, beginning with because of (1) content issues, (2) testing errors, or (3)
your weakest areas first. For example, if your assessment confidence issues. Design your study plan accordingly.
of your practice test score indicates a specific weakness As you study, use the analysis of scoring to continue
in male genitourinary content, begin with that chapter. to track your progress.
Reflect, as part of your assessment, on your pre- Aim for an 85% grade on your practice exams to
ferred learning style and personality. Remember, speed demonstrate a good level of mastery of each content
is not necessarily your best friend, and overanalyzing area. Begin working on areas in which your knowl-
can lead you to an incorrect answer choice, but careful edge may be lacking and progress to areas in which
analysis of each question is a prerequisite to success on you are stronger. Opening a book and beginning on
the exam. The union of knowledge and strategy is what page 1 may not serve you well. However, recognizing
is needed to achieve a successful outcome on the certifi- that you may be weak in cardiovascular content and
cation exam. One complements the other, and both are prioritizing your study time to concentrate on that
imperative if you are to attain your goal of becoming a content area to eliminate knowledge deficits will be
board-certified advanced-practice registered nurse. very helpful.
Use the analysis of scoring in Table 2-2 to help Any test score below 85% indicates a need to ini-
you make an accurate assessment of why you missed tiate a more aggressive and intensive exam review.
TABLE 2-2. ANALYSIS OF SCORING

Review the sample test questions that you answered incorrectly and keep track of what caused you to select
the incorrect answer. Look for a pattern.
Missed Did not Read Misread or Changed Had Forgot or Applied

key read “into” the misunderstood the content did not the
word all the question the question answer weakness recognize wrong
distractors or concept
carefully understand or
the content rationales

A score of 85% or higher, however, does not mean review class is an additional way to shore up your
that you don’t need to prepare. You should still aim knowledge base.
to review 2,000 to 3,000 sample test questions before
sitting for the exam, as well as do some basic con-
PLAN AND IMPLEMENT
tent review. An initial score below 80% means you
should aim to review a minimum of 5,000 sample test The certification exam time line and study calendar
questions before the exam, as well as complete an (Table 2-3) provide a suggested 6-week time line,
intensive content review. Attending a certification providing a countdown to exam time from the day
TABLE 2-3. CERTIFICATION EXAM TIME LINE AND STUDY CALENDAR
SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
Commitment
• Register for the exam.
• Evaluate your preferred learning style.
• Take assessment exam.
• Evaluate exam with analysis of scoring.
• Develop study plan and gather study materials.
• Fill out study calendar and begin.
• Make arrangements for going to the exam.
(Dates)
WEEK 1 Content: Content: Content: Content: Content: Content:
Score: Score: Score: Score: Score: Score:
(Dates)
Perseverance
• Continue studying.
(Dates)
(Dates)
Focus and Reward

• Focus on content areas in which you scored less than 80% on sample questions.
• Make final arrangements for going to the exam.
(Dates)
(Dates)
Source: Adapted from Hoefler, P: Successful Problem-Solving and Test-Taking for Beginning Nursing Students, ed 3. MEDS, Silver Spring,
MD, 1997, p. 111.

you register for your exam. Study a little every day. Using content maps is another approach to mas-
Improve your self-image. Believe you are a knowledge- tering content. Figure 2-1 is an example of a con-
able and competent nurse practitioner and behave like tent map approach to reviewing disease processes.
one. Stick to your study plan. Set clear-cut goals and A content map is a picture or pattern of informa-
objectives and follow them. tion. It also shows relationships between pieces of
Answer approximately 100 test questions in a spe- information. Developing content maps can help
cific content area. Assess your score. If it is above 85%, you find content areas in which you are weak and
move on. Feel confident—but continue to review sam- avoid studying content you already know. People
ple test questions. If your score is lower than 85%, use are drawn to study what they already know. They
the Analysis of Scoring in Table 2-2. feel comfortable with that information, whereas
As noted in chapter 1, both the ANCC and new information can produce anxiety. In the long
AANP exams cover pathophysiological content orga- run, however, this is not a good strategy. Few peo-
nized by body system. This is how you should organize ple can read a book and visualize the exact page,
your study time: by body system, by content areas asso- word for word, in their minds. A content map helps
ciated with populations (usually age-driven), and by you find the information in your memory, where it
the specified domains on the exam. The body system is usually stored in patterns related to other mem-
content is specified by the chapter title. We suggest ories. Using this structure, you can find out what
following the table of contents of this book, which is areas you may not completely understand. Content
modeled on the practice domains spelled out by both maps start with general information and move to
certifying bodies. After assessing your baseline knowl- specifics. They can be helpful for people who spend
edge through use of the integrated practice exams pro- so much time studying the details that they miss the
vided in this book, move on to the content areas in bigger picture.
which you scored the lowest. This will allow you to
customize your study plan and make the best use of
CONTENT MAP
your time. Remember, for some people, this might be
the neurological content; for others, it might be the
endocrine or psychiatric content, and so on.
To review disorders and help you prioritize, use the
following tips:
• Organize content by body system.

• Begin with the system you find the most
difficult.
• Review the pathophysiology of that system, if
necessary.
• List pertinent disorders of that system.
• Review incidence and contributing factors.
• Review early and late disease manifestations.
• Review the sequelae, prognoses, and life-
threatening complications.
• Determine treatment; adjust for age and/or
comorbidities.
• Review associated teaching and learning needs.
• Review coping techniques, prevention, and
health promotion.
• Remember that the certification exam focuses
on common diseases and disorders; use this
information as a tool for success and avoid
studying topics that are rarely seen in a primary
care setting. Figure 2-1

EVALUATE
Last-Minute Preparations: Relaxed
To help you evaluate your progress, consider these tips: and Ready
• Take a sample test and use the analysis of
scoring. Review one of your sample content Well, you are finally there! The day of the exam has
area tests. Why did you answer some questions arrived. Several tried-and-true techniques can help
incorrectly? Remember, active learning you get through this day with success and confidence.
improves retention. The night before the exam, get a good night’s sleep.
Last-minute all-night study sessions are not recom-
• If you forgot some content, use a content review.
mended. Since your exam will focus on comprehension
Did you not recognize or remember the content?
and analysis, cramming the night before is not a test-
If not, this would indicate a need to review
taking strategy, and it often results in increased anxiety
content using a book of condensed information
and lower test scores. However, taking time to review a
or an outline-review text, or attending a
few notes is acceptable. It might be better to do some-
certification review. It does not mean that you
thing relaxing and enjoyable like going to a movie.
should return to your textbook or class notes.
Locate the exam site before the day of the actual
• If you misunderstand a rationale, go back exam. For some, you may need to travel and stay in a
to textbooks. Did you not comprehend the hotel the night before taking the exam. Give yourself
content? For example, perhaps your basic plenty of time to travel and arrive at a reasonable time
understanding of the cardiac cycle was not in the city where you will be taking the exam. On the
thorough enough to include the severity and day of the exam, plan for possible traffic delays or bad
implications of various murmurs (i.e., which weather. Becoming lost or finding yourself stuck in traffic
ones are relatively normal physiological will only increase your anxiety. Find out how long it will
events and which ones are indicative of more take to get there and where to park when you arrive.
severe pathology). This would indicate a The day of the exam, do a few exercises to get your
need to go back to one of your textbooks or blood pumping to your brain. Eat lightly, but do have
perhaps obtain audio and/or video recordings something before taking the exam. Bring identifica-
with more detailed content and review basic tion, your registration for the exam, and a watch. Dress
pathophysiological processes. in layers. Avoid stimulants and depressants. Go light
• If the error is in test taking or you need to on the caffeine. Find the restroom and use it before
build confidence, continue to take the sample beginning the exam.
exams. Did you answer a question incorrectly Pay careful attention to the instructions and tuto-
because you missed a key word? Did you not rial for computer testing. Do deep-breathing and pos-
read all the options carefully enough? Did you itive relaxation exercises to calm yourself. In a testing
read something into the question? Did you center, others will be taking different exams and will
change an answer? Did you choose the correct have started at different times, so do not panic if peo-
answer but mark an incorrect response? All of ple come and go while you are testing. Stay focused!
these are indications of test-taking errors and Pace yourself, do not spend too long on any one
indicate an ongoing need for you to continue test question, and go with your first answer choice.
practicing your skills using sample exams. If The certification exams are not computer adaptive,
you are consistently scoring well on practice meaning that you will be able to mark a question
exams, it will make you feel more confident and and return to it later if time permits. (In computer-
comfortable with testing. adaptive exams, like the NCLEX-RN, after submitting
• Practice, practice, practice sample test your answer choice, you are not permitted to return to
questions. First use the analysis of scoring as a question and change your response.)
you grade yourself on an integrated exam. Use test-taking strategies when you do not know
Follow this with exams for specific body-system the answer. Identify distractions, such as backache
content, which will enable you to design and or neck ache, noise, reading the same questions over
update an individualized study plan that has and over, feeling tired, or thinking of your vacation.
specificity and relevance for you. For example, If these occur, stop, take a few deep breaths, refocus,
you may need to spend a week on neurological then get back on track. Mental fatigue can certainly
content but only a day on cardiac content. You play a factor when you are taking a lengthy exam.
can succeed in becoming certified! We recommend that you pace yourself accordingly.

For example, prepare ahead of time to rest between References

each set of 25 questions or so. Allow yourself to disen-
gage even for 1 minute; then, you will be better able Advanced Practice Registered Nurse Consensus
to refocus and continue answering questions. Stretch Model for Regulation: http://www.nonpf.org/default
as needed. Practice positive visualization if your mind .asp?page=26
begins to drift and you find it difficult to concentrate, American Academy of Nurse Practitioners Certifi-
thus reducing your ability to identify key words and cation Program description: http://www.aanp.org/
topics and increasing your likelihood of answering a education/aanp-certification-program
question incorrectly. Do not overcomplicate or over-
American Nurses Credentialing Center certification
analyze the test questions—everything you need to
Web page: http://www.nursecredentialing.org
know to answer the question correctly is included in
the question stem or answer choices. Move on! Think Dunphy, LM, Winland-Brown, JE, Porter, BO, and
positively about your success. Stay focused on your Thomas, D: Primary Care: The Art and Science of
goal: becoming a nationally certified advanced prac- Advanced Practice Nursing, ed 4. FA Davis, Phila-
tice registered nurse. delphia, 2015.
Begin now by using this book as suggested. After Miller, SK: Adult Nurse Practitioner Review and Resource
all, the longest journey begins with a single step. Take Manual, ed 3. American Nurses Credentialing Cen-
that step now. Turn the page and begin. ter, Silver Spring, MD, 2008.

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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)
The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.
NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.
MAKONDE LOCK AND KEY AT JUMBE CHAURO

This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]
MODE OF INSERTING THE KEY
With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
“We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
BRAZIER
Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT
SMOOTHING WITH MAIZE-COB
CUTTING THE EDGE

FINISHING THE BOTTOM
LAST SMOOTHING BEFORE

BURNING
FIRING THE BRUSH-PILE

LIGHTING THE FARTHER SIDE OF
THE PILE
TURNING THE RED-HOT VESSEL
NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK
DRAWING THE BARK OFF THE LOG
REMOVING THE OUTER BARK

BEATING THE BARK
WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT
MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN

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Primary Care Nurse Practitioner

Marlene Brennan, DNP, FNP-BC, PMHNP-BC Sandra Ripper-Brown, DNP

Denise Vanacore, PhD, CRNP, ANP-BC,

4469_Winland-Brown_FM_i-x.indd vii 3/21/17 3:04 PM

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UNIT THREE 155

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16. Musculoskeletal Problems 407

UNIT FOUR 495

UNIT FIVE 527

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APRN REGULATORY MODEL

Family/Individual Women’s Health/ Psychiatric-

Nurse Clinical Nurse Nurse

nurse practitioner. This certification aligns with the

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• Dimension 1—Clinical Management

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Nature of the Exams

Designing Your Study Plan

Last-Minute Preparations: Relaxed and Ready

This chapter has several parts. The first part actively

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Visual learners learn better from reading and writing

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TABLE 2-1. COMMUNICATION TECHNIQUES

TECHNIQUES THAT FACILITATE THERAPEUTIC COMMUNICATION

TECHNIQUES THAT BLOCK THERAPEUTIC COMMUNICATION

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TABLE 2-2. ANALYSIS OF SCORING

Missed Did not Read Misread or Changed Had Forgot or Applied

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TABLE 2-3. CERTIFICATION EXAM TIME LINE AND STUDY CALENDAR

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

Focus and Reward

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• Organize content by body system.

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For example, prepare ahead of time to rest between References

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Newala, too, suffers from the distance of its water-supply—at least

The water-supply of New Newala is in the bottom of the valley,

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAKONDE LOCK AND KEY AT JUMBE CHAURO

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

Some consolation was afforded me by a brassfounder, whom I

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE