Nurse Practitioner Certification

Examination and Practice Preparation

5th Edition (eBook PDF)
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6042_FM_i-xiv 06/02/17 11:32 AM Page vii

Contributors

Kara L. Ashley, M.Ed. Louise McDevitt, MS, ACNP-BC, ANP-BC,

Northeast Association of Learning Specialists FNP-BC, FAANP
Senior Lecturer
Victor Czerkasij, MA, MS, FNP-BC
Fitzgerald Health Education Associates, LLC
Associate Lecturer
Clinical Practice, Grace Cottage Family Practice
Fitzgerald Health Education Associates, LLC Townshend, Vermont
Clinical Practice, Skin Cancer and Cosmetic Assistant Clinical Instructor
Dermatology, PC University of Vermont Medical School and
Cleveland, Tennessee Graduate School of Nursing Family Nurse Practitioner
Adult and Pediatric Dermatology Program
Dalton, Georgia Burlington, Vermont
Carolyn Buppert, NP, JD Sally K. Miller, PhD, AGACNP, AGPCNP,
The Law Offices of Carolyn Buppert FNP-BC, FAANP
Boulder, Colorado
Senior Lecturer
Kahlil Ahmadi Demonbreun, DNP, RNC-OB, Fitzgerald Health Education Associates, LLC
WHNP-BC, ANP-BC Clinical Practice, Nevada Health Center
Instructor Las Vegas, Nevada
Clinical Professor
College of Nursing
Drexel University College of Nursing and Health
Medical University of South Carolina
Professions
Clinical Practice, Women’s Health Nurse Practitioner
Philadelphia, Pennsylvania
Palmetto Primary Care Physicians
Charleston, South Carolina Monica N. Tombasco, MS, MSNA,
Susan Feeney, DNP, NP-C, FNP-BC FNP-BC, CRNA
Senior Lecturer Senior Lecturer
Fitzgerald Health Education Associates, LLC Fitzgerald Health Education Associates, LLC
Clinical Practice, Wright and Associates Family Healthcare Emergency Medicine Nurse Practitioner Huggins
Amherst, New Hampshire Hospital, Wolfeboro, NH
Family Nurse Practitioner Program Coordinator, Certified Registered Nurse Anesthetist
University of Massachusetts Worcester Catholic Medical Center, Manchester, New Hampshire
Graduate School of Nursing, Worcester Massachusetts Christy M. Yates, MS, FNP-BC, NP-C, AE-C
Jordan Hopchik, DNP, RN, FNP-BC, CGRN Senior Lecturer
Gastroenterology Nurse Practitioner Fitzgerald Health Education Associates, LLC
Philadelphia VA Medical Center Clinical Practice, Family Allergy and Asthma
Louisville, Kentucky
Scharmaine Lawson-Baker, DNP, FNP-BC, FAANP
Advanced Clinical Consultants
New Orleans, Louisiana
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Acknowledgments
This book represents a sum of the efforts of many people.
I thank my family, especially my husband, and business
partner, Marc Comstock, for their support and patience as
they lived through this experience.
I thank the staff of Fitzgerald Health Education Associates
for sharing me with this project for many months. To the
contributing authors, your insight has helped increase the
value and helpfulness of this publication.
I thank the patients and staff of the Greater Lawrence
(MA) Family Health Center, where I have practiced for more
than 30 years, as they continue to serve as a source of inspi-
ration as I developed this book. Gracias.
I thank Susan Rhyner, Amanda Minutola, and the F.A. Davis
staff for their ongoing encouragement.
Last but not least, I thank the thousands of nurse practi-
tioners who, over the years, have participated in the Fitzgerald
Health Education Associates Nurse Practitioner Certification
courses. Your eagerness to learn, thirst for knowledge, dedi-
cation to success, and commitment to excellence in healthcare
provision continue to inspire me. I am privileged to be part of
your professional development.
ix
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6042_FM_i-xiv 06/02/17 11:32 AM Page xi
Preface
The scope of practice of the nurse practitioner is wide, encom-
passing the care of the young, the old, the sick, and the well.
This book has been developed to help the nurse practitioner
develop the knowledge and skills to successfully enter nurse
practitioner (NP) practice and earn certification, an important
landmark in professional achievement.
This book represents a perspective on learning and prac-
tice developed during my years of practice at the Greater
Lawrence (MA) Family Health Center and as an NP and
professional speaker. In addition, my experiences through
the years of helping thousands of NPs achieve professional
success through conducting Fitzgerald Health Education
Associates NP Certification and Advance Practice Update
Courses influenced the development and presentation of
the information held within.
This book is not intended to be a comprehensive clinical
text; rather, it is meant to be a source to reinforce learning
and a guide for the development of the information base and
critical thinking skills needed for safe, entry-level NP practice.
The reader is encouraged to answer the questions given in
each section and then check on the accuracy of the response.
The discussion section is intended to enhance learning
through highlighting the essentials of primary care NP prac-
tice. The numerous tables can serve as a quick-look resource
not only as the NP prepares for entry to practice and certifi-
cation but also in the delivery of ongoing care.
—MARGARET A. FITZGERALD, DNP, FNP-BC, NP-C,
FAANP, CSP, FAAN, DCC, FNAP
President
Fitzgerald Health Education Associates, LLC
North Andover, Massachusetts
Family Nurse Practitioner
Greater Lawrence (MA) Family Health Center
Lawrence, Massachusetts
xi
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Contents

Introduction Understanding Test Design and Theory I-1

Chapter 1 Health Promotion and Disease Prevention 1

Chapter 2 Neurological Disorders 25
Chapter 3 Skin Disorders 47

Chapter 4 Eye, Ear, Nose, and Throat Problems 81

Chapter 5 Cardiac Disorders 109

Chapter 6 Respiratory Disorders 133

Chapter 7 Gastrointestinal Disorders 159

Chapter 8 Male Genitourinary System 197

Chapter 9 Musculoskeletal Disorders 217

Chapter 10 Peripheral Vascular Disease 261

Chapter 11 Endocrine Disorders 275

Chapter 12 Renal and Urinary Tract Disorders 309

Chapter 13 Hematological and Select Immunological Disorders 325

Chapter 14 Psychosocial Disorders 339

Chapter 15 Female Reproductive and Genitourinary Systems 369

Chapter 16 Older Adults 399

Chapter 17 Pediatrics 425

Chapter 18 Childbearing 493

Chapter 19 Professional Issues 515

Index 529

xiii
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6042_Intro_I1-I8 06/02/17 11:32 AM Page I-1
Introduction:
Understanding Test
Design and Theory
A Foundation
for Success
Certification tests are intimidating for every examination can-
didate. In addition to anxiety over content mastery, certifica-
tion examinations take place outside of the familiar clinical or
classroom setting, and differ greatly from the assessments that
a student encounters in an academic program. As a result,
preparing for and taking these standardized tests requires a
shift in approach and preparation for the examination that is
different from the one that successfully saw you through your
graduate program. Purchasing this book and immersing your-
self in high-yield test preparation is one of the best steps you
can make in being successful on the nurse practitioner (NP)
boards. But an equally critical step is familiarizing yourself
with the basics of test design and theory, to strategically
understand how board examinations are written to approach
the assessment of a candidate. Knowing the strategy of the
examination is just as important as knowing the content being
assessed on the examination.
Primary Care
Mind-Set
Keep in mind that the purpose of the NP boards is to deter-
mine whether you possess and can apply the knowledge base
needed to be a safe, entry-level NP. When studying for the
family or adult-gerontology examinations, remember that
this practice is set in primary care, physically distanced from
an acute care facility. These are not specialty, subspecialty, or
acute care examinations. Adopting this mind-set from the
outset is a primary step in preparing for this critically impor-
tant examination.
Consider that standardized tests differ from teacher-
generated tests: they are global in focus, rather than limited
to a particular course, and rely heavily on the ability to
form associations, rather than recall specific details. More-
over, more than 50% of the questions on standardized tests
will ask you to apply your knowledge in a manner of con-
text fundamentally different from the one in which you
studied in order to test your critical thinking and clinical
application skills.
Despite the major differences between assessment in the
context of a graduate program and standardized tests, roughly
four of every five test takers who engage in focused, purposeful
study pass the examination on their first attempt. Part of effec-
tive test preparation involves “demystifying” test design, learn-
ing how to “unlock” questions, engaging in preparation that
is most effective for your individual learning style, and know-
ing what to expect on examination day. These steps are just as
important as the robust clinical knowledge base that you need
to access and apply when answering questions. The content
and review program provided in this text will help you secure
the broad and deep knowledge base needed to be a safe, entry-
level primary care nurse practitioner.
Higher-Order
Thinking
Expect that your certification examination will emphasize
questions that stress higher-order thinking skills such as
analysis, synthesis, and evaluation of concepts and relation-
ships. Anticipate few questions that focus on facts, details,
and particulars. The testing body is expecting you to think as
a competent, entry-level nurse practitioner and employ adap-
tive expertise as you approach your test, just as you would
apply your clinical expertise in the examination room. NP
certification candidates who are experienced adaptive experts
use conceptual knowledge, including pathophysiology, phar-
macology, and principles of assessment, diagnosis, interven-
tion, and evaluation, as the basis for thinking but are open to
flexibility of thought in relationship to a new context.
On the certification examination, this is an important
mind-set to maintain, as many questions will present you
with a brief patient scenario, unlike the one you typically
experience in clinical practice. Moreover, on test day, you
do not have the ability to ask additional questions that could
help to bring the “answer” into focus. Therefore, you need
to think as an adaptive expert: Based on the strong concep-
tual foundation, how do I apply what I know in this new
context?
I-1
6042_Intro_I1-I8 06/02/17 11:32 AM Page I-2
I-2 INTRODUCTION ■ Understanding Test Design and Theory
Unlocking the
Question
The multiple-choice question is the bane of many a test taker.
In recent years, some educators are moving away from the
traditional multiple-choice test in favor of questions that
encourage students to interact with the test material in a more
dynamic way. Nevertheless, the multiple-choice question is
a standard instrument used in most high-stakes tests, such as
the NP boards.
The multiple-choice question is more easily tackled if you
understand:
• How it is designed
• What it is attempting to measure
• Effective strategies for decoding and answering the
question
Keep in mind that practice questions are a helpful way to
demonstrate—but not build—your practice base. Work first
on increasing and securing your clinical knowledge base
prior to moving to practice questions. When using this book,
it is important to study the didactic content and complete the
practice questions.
Multiple-choice questions are made up of multiple parts:
• A stem (scenario, context)
• Interrogatory (essential question, action)
• Answer choices
Multiple-choice tests do not lend themselves to plentiful ex-
traneous detail. Stem scenario or context is there to support,
not confuse, you in your analysis. Typical answer choices con-
sist of one best answer, one (obviously) wrong answer, and two
partially correct answers. Note that partially correct answers
can cause you to second-guess yourself. Effective test takers
will learn to differentiate between partially correct (the “some-
times” or “yes . . . but”) and the most common, best answer.
On high-level tests, the difference between the best answer and
the distractor answers will not always be clear. You will be
asked to weigh options, interpret data, and arrive at the correct
action within the context or scenario of the test question.
There could be many times when you feel that a question
has more than one good answer choice. In these cases, take
another look at the question and then choose the response
most specific to the given situation. Sometimes questions that
relate to presentation of disease have more than one applica-
ble answer. The response with the most common presenta-
tion is likely to be correct. For example, an adult with
bacterial meningitis can present with nuchal rigidity and
papilledema. Because nuchal rigidity is seen in most adults with
this diagnosis, and papilledema is found far less often, nuchal
rigidity is a better choice. Childhood development questions
often have more than one correct response. A 4-month-old
is expected to roll stomach to back and smile. Smiling is a
developmental milestone achieved by age 2 months, whereas
rolling is typically not seen until an infant is 4 months old.
Rolling stomach to back is the best response. Remember:
Test questions are designed to have one best, but perhaps not
perfect, answer.
Although there are some test items that assess factual
knowledge, such as identifying an anatomical landmark, the
majority of the test questions are seeking to measure higher-
order thinking and reasoning skills. These items are testing
your clinical judgment and expertise. Most items test your
ability to assess or develop a plan of intervention for a clin-
ical situation. You should expect to apply clinical decision-
making skills to the test question. Make sure you think
through each question. In particular, bear in mind how the
pathophysiology of the condition affects the presentation
and treatment.
In clinical practice, you would likely gather more infor-
mation than is given in a scenario in one of the test questions.
During the certification examination, you have to decide on
the best response given the information in front of you by
applying sound clinical judgment. Remember: Multiple-
choice tests do not lend themselves to plentiful extraneous
detail. Decide whether extra information found in a particu-
larly long answer is pertinent to the question and not simply
a distractor.
When keeping in mind major information about pre-
senting issues, pharmacology, and best practices, it can be
easy to lose sight of important little words—words such as
but, however, despite, except, and if. These are common
cuing words that tell you that things may not always be as
simple as they appear. These words can indicate a shift, a
possible contradiction or contraindication, and a condi-
tional situation or scenario. Pay attention to these words. A
careful test taker can use these words to construct a strategy
for answering the question. For example, in a question that
reads, “All of the following are symptoms of ‘X’ except,” you
can treat this as a mini true/false question. You will be given
three or four “true” choices and one “false” choice. That
false choice is your answer. On a related note, be wary of
options that include extreme words, such as “always,”
“never,” “all,” “best,” “worst,” and “none.” Seldom is any-
thing absolute in healthcare.
Sometimes identifying the verb in the question can help
you determine the purpose of the question. In addition, look
at the information presented and then ask yourself, “Is this
question a test of the ability to gather subjective or objective
information? Is this question a test of the ability to develop
a working diagnosis or to plan a course of intervention, or
evaluation of response to care?” This thinking helps focus
your thought process as you choose the answer. Read each
question and all responses thoroughly and carefully so that
you mark your option choice only after you are sure you
understand the concept being tested in the question.
Answering a question quickly might lead to choosing a
response that contains correct information about a given
condition, but might not be the correct response for that
particular question. As you use this book to help develop
your knowledge base, deciding on the best answer will
become increasingly easy.
Remaining mindful of a conceptual framework that works
for you can aid question comprehension and accuracy in your
answering. If you are mathematically or visually minded, a
6042_Intro_I1-I8 06/02/17 11:32 AM Page I-3
INTRODUCTION
good strategy might be to think of the question as a math
problem or scientific equation with (patient) + (presentation)
+ (context) = (best action). Consolidating and storytelling
work for people who need to “talk through” answers and their
thinking to find the best result. Turn the question into a
story and predict the ending before you look at the possible
answers. When in doubt, process of elimination can be a use-
ful exercise. By eliminating wrong answers, you can narrow
down your choices by rereading the question with remaining
possibilities in mind.
With the strategies we have covered here, let’s look at the
following test item:
You see 18-year-old Sam, who was seen approximately
36 hours ago at a local walk-in center for treatment of ear
pain. Sam was diagnosed with (L) acute otitis media, and
amoxicillin was prescribed. Today, Sam states that he
has taken five amoxicillin doses since the medication was
prescribed but continues to have discomfort in the affected
ear. Left tympanic membrane is red and immobile.
This is an action-oriented question, directing you to con-
sider Sam’s care and chief complaint. Based on the scenario
presented, you can assume the following:
• Because no chronic health problems are mentioned,
implied is that Sam is a young adult who is typically in
good health.
• Acute otitis media (AOM) is a common episodic illness
usually caused by Streptococcus pneumoniae,
Haemophilus influenzae, Moraxella catarrhalis, or
respiratory virus.
• A first-line antimicrobial for AOM treatment is amoxi-
cillin. When given in a sufficient dose, this antibiotic is
effective against S. pneumoniae and both H. influenzae
and M. catarrhalis that do not produce beta-lactamase.
Nearly all M. catarrhalis and about 30% of H. influenzae
isolates produce beta-lactamase, rendering amoxicillin
ineffective. Clavulanate is a beta-lactamase inhibitor, and
when given in conjunction with amoxicillin is an effective
treatment option when AOM fails to respond to amoxi-
cillin alone.
• As inflammation and purulent exudate forms in the
middle ear, a small space rich with pain receptors, otalgia
is an expected finding in AOM. This usually resolves
after 2 to 3 days of antimicrobial therapy.
• Tympanic membrane immobility is a cardinal sign of
AOM that despite antimicrobial therapy does not resolve
for many weeks. A patient report of otalgia is also needed
to make the AOM diagnosis.
The following answer choices are given:
A. Advise Sam to discontinue the current antimicrobial and
start a course of amoxicillin with clavulanate.
B. Perform tympanocentesis and send a sample of the
exudate for culture and sensitivity.
C. Have Sam return in 24 hours for reevaluation.
D. Recommend that Sam take an appropriate dose
of ibuprofen as needed for discomfort for the next
2 to 3 days.
■ Understanding Test Design and Theory I-3
Which answer included the best course of action for Sam?
Let’s review the answers to see which one is correct and why.
A. Advise Sam to discontinue the current antimicrobial and
start a course of amoxicillin with clavulanate.
• Choosing this response infers amoxicillin treatment
failure. AOM antimicrobial treatment failure is usually
defined, however, as persistent otalgia with fever after
72 hours of therapy. Sam has taken fewer than 2 days
of therapy, an interval too short to assign continued
symptoms to ineffective antimicrobial therapy. In
addition, there is no report of Sam’s condition wors-
ening in the short time since he was initially seen.
Therefore, prescribing an antimicrobial with a broader
spectrum activity, such as amoxicillin/clavulanate,
is not warranted at this time. This is an excellent
example of having a knowledge base that includes
the standards of evidence-based practice is critical.
B. Perform tympanocentesis and send a sample of the
exudate for culture and sensitivity.
• AOM treatment is based on empirical antimicrobial
therapy in which the clinician chooses an agent with
activity against the most likely organisms in a given
condition, bearing in mind the most common resistant
pathogens. Tympanocentesis is indicated only with
treatment failure after 10 to 21 days of antimicrobial
therapy with a second-line agent, with the goal of
detecting a significantly resistant organism; at that
point, culture and sensitivity of middle ear exudate
would be appropriate, usually with referral to otolaryn-
gology to have this procedure done. With fewer than
2 days of treatment, tympanocentesis is not indicated.
C. Have Sam return in 24 hours for reevaluation.
• If Sam’s condition worsens in the next day, reevalua-
tion is prudent. However, choosing this option ignores
Sam’s complaint of pain.
D. Recommend that Sam take an appropriate dose of ibupro-
fen as needed for discomfort for the next 2 to 3 days.
• Choosing option D response infers that treating Sam’s
pain is the most appropriate intervention. This is the
best response and the correct answer.
Now consider this question: Which of the following
best describes asthma? No clinical scenario is presented;
the question simply asks for a definition of a pathological
state. When considering the options, the test taker must
recall that asthma is a chronic inflammatory disease of the
airways involving an increase in bronchial hyperrespon-
siveness. This condition leads to a potentially reversible
decrease in FEV1-to-FVC ratio and is an example of how
the NP boards often include questions on the clinical pres-
entation of pathophysiology. This type of answer lends
itself well to becoming a “true/false” question. As you read
each answer, ask yourself whether a choice is true or false.
You are looking for the “true” answer. If answers seem par-
tially true, or true sometimes, select the one that is mostly
true, most of the time.
6042_Intro_I1-I8 06/02/17 11:32 AM Page I-4
I-4 INTRODUCTION ■ Understanding Test Design and Theory
Here are your answer choices:
A. intermittent airway inflammation with occasional
bronchospasm
B. a disease of bronchospasm leading to airway
inflammation
C. chronic airway inflammation with superimposed
bronchospasm
D. relatively fixed airway obstruction
Let’s again look at the choices and reveal the correct
answer.
A. intermittent airway inflammation with occasional
bronchospasm
• Because asthma is a chronic, not intermittent, inflam-
matory airway disease, this option is incorrect.
B. a disease of bronchospasm leading to airway
inflammation
• Because asthma is first a chronic inflammatory airway
disease that leads to airway hyperresponsiveness, this
option is incorrect.
C. chronic airway inflammation with superimposed
bronchospasm
• This option most closely matches the definition of
asthma and is the best option.
D. relatively fixed airway obstruction
• Because the airway obstruction in asthma is largely
reversible, this option is incorrect. This answer is more
descriptive of chronic obstructive pulmonary disease.
Review That Works
for You
With test design in mind, it’s time to think about planning
an effective study strategy. As you learned in your graduate
studies, there are many “right” ways to study. The most
important factors to your success, regardless of learning style,
depend on an organized and purposeful study plan. This issue
of time needed for certification preparation is unique to each
examination candidate. That said, one of the major pitfalls in
study is the failure to put aside the time to prepare. Map out
the demands on your time in the first months after complet-
ing your NP program, including work hours, family, personal
and professional commitments, as well as time you have
perhaps set aside for some well-deserved downtime. After
doing this, set up a schedule of study time, allotting a greater
amount of time to areas of knowledge deficit and less to areas
in which you only need to refresh your knowledge base. Make
sure you cover all areas listed as possible examination con-
tent. Plan your date for certification only after a period of
well-planned, systematic, certification-focused study.
Start with reviewing the information on the examination
content. Make a list of the areas in which you feel your knowl-
edge base is secure and in which just reviewing material to
refresh your memory will likely suffice. Then make a second
list in which you identify areas of weaknesses and areas in
which you need to concentrate your review. If you have taken
an NP review course, you are likely aware that the content of
certain parts of the program were truly review, whereas other
sections helped to point out areas in which you needed to
expand on your knowledge base. Knowing on which areas to
best concentrate your study helps you decide how to allocate
your study time.
As you study, please keep in mind that the NP certification
examination tests your ability to know the following:
• Why a patient is at risk for a problem.
• How a clinical problem has developed.
• What is the most likely clinical presentation of the
condition.
• Why a given intervention is effective.
• How that intervention works.
• What is the most likely clinical outcome.
• Why this clinical problem is of significance to the overall
healthcare system.
A poor approach to preparing for the examination and
practice is to memorize information so you know what to do
but not why you are doing it, in both the examination room
and as part of the larger healthcare system. A better approach
to preparing for the examination and practice is to under-
stand concepts and apply knowledge so you know what to do
and why you are doing it. The Fitzgerald Health Education
Associates Inc. NP Certification Examination Review and
Advanced Practice Update prepares you in the why, how, and
what of NP practice, as well as helping to prepare you for suc-
cess on the NP boards. Using this book will help greatly in
building your knowledge base so that you are able to apply
information to answer questions to help you in your pursuit
of certification.
As you work through practice questions, and do this only
after working on building your knowledge base, make a note
next to each with words or symbols that indicate how certain
you are of your answer. For some, you will be “sure” or “con-
fident” that an answer is correct; for others you may be
“mostly” or “somewhat sure”; and for others, you are likely
offering a best guess. After you score your pretest, examine
how your answers match up with your predicted perform-
ance. If you marked yourself “confident” on an item you got
wrong, start by studying the question and answer choices
carefully to glean the possible reasons you might have
selected the wrong answer for that particular question. Ask
yourself the following: Did I understand the context prop-
erly? If so, did I misinterpret or misread the question? Was
there unfamiliar content or vocabulary that led me to an
incorrect conclusion? What was it about the distractors that
distracted me? If you correctly answered a question about
which you were not completely certain of the best answer,
ask yourself what information in the context, action, or
answer choices helped to lead you in the right direction.
Frequent pretesting will not only help you to become more
comfortable on test day, it can also help you to be more effec-
tive at unlocking a question.
When studying for the NP boards, some people will work
best alone, whereas others benefit from collaborating with a
6042_Intro_I1-I8 06/02/17 11:32 AM Page I-5
INTRODUCTION
study group. Study groups can be helpful and a terrific way
to share information and resources. Alternatively, study
groups can yield a poor return on time invested if all mem-
bers are not similarly committed. Study groups can meet in
person or virtually, such as via Skype or Google groups. The
following contains some guidelines for forming a successful
study group.
All group members must treat attendance and participa-
tion as they would any other professional commitment, such
as work or school. Well in advance, set a schedule, place, and
time to meet, as well as a topic for the meeting. Plan a start
and end time, with a clear objective for the session. Study
groups usually work best when a group member volunteers
to research and present information on a subject on a prede-
termined schedule. The presentation is typically followed by
a discussion of the issue and a review of sample examination
questions and rationales for the correct response. The leader
of a given session should also assume responsibility for keep-
ing the discussion on track, facilitating the efficient use of
time and resources.
To help avoid the group deteriorating into a chat session,
plan for a short period of socialization following high-yield
study sessions. Here is an example of a session planned by a
successful study group with three members, Sarah, Ben, and
Helena. “The session will start promptly at 7 p.m. and end at
9 p.m., with the objective of identifying the risk factors, clin-
ical presentation, assessment, and intervention in commu-
nity-acquired pneumonia in the adult. Sarah is the presenter
and also group leader for the evening and is responsible for
keeping us on track. A social period from 9 to 9:30 p.m. will
follow. We will meet at Helena’s apartment. Ben is responsi-
ble for refreshments.”
Whenever possible, try to create a study situation that will
mimic the actual test. Set a timer and be mindful of pacing
yourself. During the test, expect to answer about 60 to 70 or
more multiple-choice questions per hour. This means you
will likely be spending less than a minute, on average, on
each question. Some questions take only a few seconds,
whereas others require more time for thought. Check yourself
at 15- or 20-minute intervals to determine whether you
are progressing at an acceptable rate, setting a number of
questions that you should have answered by a certain time.
Managing Nerves
During Review and
on Test Day
Everyone who sits for one of the certification examinations
is anxious to some degree. This anxiety can be a helpful emo-
tion, focusing the NP certification candidate on the task at
hand: studying and successfully sitting for this important
examination, a tangible end product of the candidate’s grad-
uate or postgraduate education. When excessive, however,
anxiety can get in the way of success. Stress yields anxiety,
anxiety yields stress; one can be viewed as the product of the
■ Understanding Test Design and Theory I-5
other. The stress of preparing for an important examination
triggers the sympathetic nervous system to undergo Seyle’s
three phases of the general adaptation syndrome: alarm,
resistance, and exhaustion. In the alarm stage, perhaps trig-
gered by contemplating the preparation needed to achieve
certification success, the hypothalamus activates the auto-
nomic nervous system, triggering the pituitary and the body
defenses, resulting in a heightened sense of awareness of
surroundings, alertness, and focus. At this level of arousal,
studying for and taking a test often yield great results. A well-
prepared examination candidate is highly focused on what
needs to be done to be successful on the examination. Dis-
tractions can be filtered out; extraneous information can be
discarded in favor of the essentials. During the examination,
anxiety and knowledge intersect; information retrieval is
facilitated, and examination questions are fluidly processed.
Difficult examination items are usually put in perspective,
with the test taker recognizing that most items were answered
with relative ease. The NP certification candidate emerges
from the test feeling challenged but confident.
Although a moderate amount of anxiety is natural, and
even useful, many candidates can find themselves struggling
with anxiety that is causing physical or emotional distress.
The process of completing a rigorous course of graduate
education and study can result in a protracted period of
stress. Now, the formerly helpful stress leads to the second
stage of the general adaptation syndrome, resistance, in which
epinephrine is released to help counteract or escape from the
stressor. At that time, the feeling of milder anxiety present in
the first stage gives way to a sense of greater nervousness,
often accompanied by uncomfortable physical sensations
such as dry mouth, tachycardia, and tremor. Studying or test
taking becomes difficult; information retrieval is inhibited.
This stage is mentally and physically taxing and, if left
unchecked, can lead to exhaustion, complicating the chal-
lenging task of successfully completing the certification
examination. Although the reaction is most severe at the time
of the test, most people who have severe test-taking anxiety
have a similar, although milder, reaction with the deep study
needed to prepare for a critical examination such as NP
certification.
The following scenario describes a person with a problem-
atic case of studying-testing anxiety:
The NP certification examination candidate is having a tough
day, with a work shift that stretched for 3 unexpected hours and
an unusually long commute, all following a poor night’s sleep as
a result of a noisy neighborhood party. To counteract this, the
candidate drank a few extra cups of strong coffee and drank an
“energy drink,” really nothing more than a can of sugar and
caffeine. She also skipped lunch and made a quick trip to a fast-
food restaurant for some fries as a snack. Studying was part of
today’s plan, however, so she sits down to prepare for the
examination with great intentions of reviewing critical
information. Surrounded by great stacks of study material, the
NP candidate thinks about what might be on the examination
and ponders the wide scope and knowledge base needed to be
successful. Now the candidate becomes aware of a dry mouth and
tight feeling in the throat. Determined, she sits down and decides
6042_Intro_I1-I8 06/02/17 11:32 AM Page I-6
I-6 INTRODUCTION ■ Understanding Test Design and Theory
to study about antimicrobial therapy. The words on the page
seem to blur when the candidate tries to read about the spectrum
of activity of an antibiotic; then, having difficulty keeping this
information straight, she decides to skip that and focuses on
memorizing a few antibiotic dose ranges, information that is
unlikely to be on the boards. Even with repeated tries, the NP
candidate cannot keep this information at hand and now
becomes even more anxious, feeling tension in the back of her
neck and a rapidly beating heart. The candidate now tries a few
practice examination questions but answers three questions
about the appropriate use of antimicrobial therapy in acute otitis
media incorrectly. Now, even the thought of sitting for the
examination causes the NP candidate to freeze.
In an ideal world, we could all control schedules and set
aside vast periods of calm, focused review. Life, however, is
complicated. Although developing a study schedule is impor-
tant, rescheduling study time is likely a good idea when a day
has been particularly difficult. Trying to learn when exhausted
and stressed by other influences is often counterproductive.
Certain scents can be helpful for putting the NP candidate in
the right frame of mind to study, particularly under less-than-
ideal conditions. These include basil, cinnamon, lemon, and
peppermint for mental alertness and chamomile, lavender,
and orange for relaxation.
Learning a relaxation technique to use before studying or
test taking can help you start your review session with a clear
mind and shift your focus from whatever events or stress your
day may have contained. You can also employ these same
techniques on test day to help center yourself if you feel over-
whelming anxiety begin to creep in. Start the session by read-
ing or repeating a positive message about being successful on
the examination. Avoid excessive amounts of caffeinated
beverages prior to studying, which can add to anxious feel-
ings. Eat a light but nourishing meal containing complex car-
bohydrates, fruits or vegetables, and high-quality protein to
feed the body and mind. Avoid refined sugars and excessive
fat intake, which can sap energy and derail quality study.
The NP candidate’s anxiety started when pondering the
wide range of possible topics on the certification examina-
tion. Starting the session by studying a narrowly focused topic
with a specific outcome goal rather than simply studying
might have averted this. Setting up a system of study can
enhance the success of a study session further. One method
is the SQ4R system, in which one surveys the study informa-
tion to establish goals; formulates questions about the infor-
mation; and then reads to answer these questions, followed by
reciting the responses to the original questions, and reviewing
to see whether the original goals were met. Study and test-
taking anxiety can also be tamed with the help of a learning
specialist who can work with the NP candidate to develop the
needed skills. Learning specialists can usually be contacted
through the academic support centers at universities.
Test Day
You have devoted years of study and months of preparation to
this day, and this very thought can be daunting. Approaching
test day with an empowered mind-set can help alleviate fears
and prepare you for what lies ahead. Let’s assume you have
devoted a large amount of time to a purposeful and organized
study regimen, and you are starting to think about the test day
itself. Coaches often advise their athletes to avoid anything new
on game day. You will be wise to heed this advice as well. This
is not the time to change your diet, caffeine intake, medica-
tions, or sleep schedule. The test environment will be different
from what you are used to, so try to keep your routines as close
to “normal” for you as possible.
Visit the Web site of the certifying body to learn all that
you can about test center rules, what you are and are not
allowed to bring to the test site, and information about pacing
and breaks. Usually the testing agency has a “test drive” video
of what to expect with the examination software and the like.
On test day, leave yourself plenty of time to arrive at your test
center, get settled, and enter the test without feeling rushed.
Be sure to have a government-issued photo ID as well as
copies of all confirmation numbers and e-mails from the test
center or organization. Expect that video surveillance will be
used in test centers to limit fraud and ensure security. At
many test centers, you will be asked to empty your pockets
and place all personal items in a locker provided for your use.
As part of your review, you should have some practice
pacing yourself as you answer the test questions. Remember,
you will have about 1 minute per test item. Don’t get bogged
down on a question or questions part of the way through the
examination. If you are stumped by a question, use the testing
software’s highlighting option to mark the question, answer
the question to the best of your ability, move on, with a plan
to return to this item at the end of the test. Do not be sur-
prised if you highlight more questions earlier in the exami-
nation and less as you progress and are more comfortable
with the test format and your brain is “warmed up.” Remind
yourself that you have answered many questions with relative
ease. Finish all of those questions that you can answer and
then come back later to process the problematic questions.
Expect that the topics you studied will be presented in ran-
dom order. A question on diabetes mellitus follows one on
hypertension and can be preceded by a question on women’s
health.
Preparing for and taking the NP certification examination
takes focus, determination, and courage. You have devoted
years of study and months of preparation to this endeavor.
Approaching test day with an empowered mind-set can help
alleviate fears and prepare you for what lies ahead. Emphasize
context and adaptive expertise over memorization, become
a master at “unlocking” test questions, and be honest with
yourself about your learning style and study habits as you
prepare to set yourself up for the best outcome.
Consider these clinical practice and certification tips as
you prepare:
• Remember that common disease occurs commonly and
that the uncommon presentation of a common disease
is more common than the common presentation of an
uncommon disease. The fundamental tools of NP prac-
tice include the ability to procure comprehensively yet
6042_Intro_I1-I8 06/02/17 11:32 AM Page I-7
INTRODUCTION
succinctly the information needed to develop accurate
diagnoses. Gathering the needed subjective and objective
information in the care of a person with common acute,
episodic, and chronic health problems is the most impor-
tant skill the NP can develop. Develop the skill of taking a
thorough yet concise health history that is pertinent to the
patient’s presenting complaint or health problem. As you
proceed through the history, recall the rationale behind
each question you ask and how a given response impacts
the possible etiology of the patient’s health problem. Know
how to perform a thorough yet succinct symptom analysis.
It is during this process that the detective work of diagnosis
starts. Use the physical examination to confirm the
findings of the health history.
• Remember that the physical examination is guided by
the health history, not the other way around. The NP
has the responsibility of arriving at a diagnosis, developing
a treatment plan, and providing ongoing evaluation of
response to treatment.
• To maximize your experience in your clinical rotations,
learn to recognize the typical presentation for the
10 most common health problems that present to
your practice site, including chief complaint and
physical examination findings, differential diagnosis,
needed diagnostics, intervention, and ongoing evalua-
tion. Armed with this information, you can focus your
study on a thorough knowledge of the assessment and
treatment of these conditions. As an adult learner, carry-
ing this applied learning to the boards helps make your NP
education come alive.
Ask your preceptor to save laboratory results, ECGs, and
other diagnostics for you to review at the next session. Do so
with a clean eye, as if you were developing a plan of interven-
tion or further diagnosis for the patient. This will help hone
your clinical skills. If you prescribed an intervention but will
not have the opportunity to see the patient at a follow-up
visit, ask your preceptor for an update. Family, cultural,
community, developmental, and environmental factors as
well as lifestyle and health behaviors influence patient health
and the interaction between the NP and the patient. As an
advanced practice registered nurse, the NP provides holistic,
wellness-oriented care on an ongoing or episodic basis.
■ Understanding Test Design and Theory I-7
• Remember to address a patient’s primary, secondary,
and tertiary healthcare needs at every visit. Check for
needed immunization, screening tests, and follow-up on
previous health problems with every encounter. Think
long-term. Envision working with patients during the years
ahead and the health problems you may help a person
avoid by working together. The healthcare provided by the
NP is guided by health and wellness research. The NP is
accountable for his or her ongoing learning and profes-
sional development and is a lifelong learner. The NP is
also knowledgeable in accessing resources to guide
evidence-based care.
• Ask preceptors and peers what references are most
helpful for that particular practice. Armed with this
information, develop your own reference library that you
can use with ease. Your investment in the time and money
it may take to gather these resources will pay off in your
practice.
Using these principles as you study for your NP boards
will increase your likelihood of success with certification as
well as your transition to NP practice. Good luck—the world
is waiting for the contributions that you will bring!
References
Nugent P, Vitale B. Test Success: Test-Taking Techniques for
Beginning Nursing Students. 6th ed. Philadelphia, PA:
F.A. Davis; 2012.
Bloom BS, ed. Developing Talent in Young People.
New York, NY: Ballantine Books; 1985.
Hatano G, Inagaki K. Two courses of expertise. In: Stevenson
H, Azuma H, Hakuta K, eds. Child Development and
Education in Japan. New York, NY: Freeman; 1986.
Mastering tests. http://web.mit.edu/uaap/learning/test/
index.html.
Sefcik D. How to Study for Standardized Tests. Sudbury,
MA: Jones & Bartlett; 2012.
Taking multiple choice exams. http://people.uwec.edu/
ivogeler/multiple.htm.
Test-taking strategies. https://casc.byu.edu/testtaking-
strategies.
6042_Intro_I1-I8 06/02/17 11:32 AM Page I-8
6042_Ch01_001-024 06/02/17 11:56 AM Page 1
Health Promotion
and Disease Prevention
Health Promotion
and Disease
Prevention
1. An example of a primary prevention measure for a
78-year-old man with chronic obstructive pulmonary
disease is:
A. reviewing the use of prescribed medications.
B. conducting a home survey to minimize fall risk.
C. checking FEV1 (force expired volume at 1 second)
to FVC (forced vital capacity) ratio.
D. ordering fecal occult blood test (FOBT).
2. Which of the following is an example of a primary
prevention activity in a 76-year-old woman with
osteoporosis?
A. bisphosphonate therapy
B. calcium supplementation
C. ensuring adequate illumination in the home
D. use of a back brace
3. Secondary prevention measures for a 78-year-old man
with chronic obstructive pulmonary disease include:
A. screening for mood disorders.
B. administering influenza vaccine.
C. obtaining a serum theophylline level.
D. advising about appropriate use of car passenger
restraints.
4. Tertiary prevention measures for a 69-year-old woman
with heart failure include:
A. administering pneumococcal vaccine.
B. adjusting therapy to minimize dyspnea.
C. surveying skin for precancerous lesions.
D. reviewing safe handling of food.
5. Which of the following products provides passive
immunity?
A. hepatitis B immune globulin (HBIG)
B. measles, mumps, and rubella (MMR) vaccine
C. pneumococcal conjugate vaccine
D. live attenuated influenza vaccine (LAIV)
1
6. Active immunity is defined as:
A. resistance developed in response to an antigen.
B. immunity conferred by an antibody produced in
another host.
C. the resistance of a group to an infectious agent.
D. defense against disease acquired naturally by the
infant from the mother.
7. Which of the following is usually viewed as the most
cost-effective form of healthcare?
A. primary prevention
B. secondary prevention
C. tertiary prevention
D. cancer-reduction measures
8. An 18-year-old woman with allergic rhinitis presents for
primary care. She is sexually active with a male partner
and is 1 year post-coitarche; during that time she had
two sex partners. An example of a primary prevention
activity for this patient is:
A. screening for sexually transmitted infection.
B. counseling about safer sexual practices.
C. prescribing therapies for minimizing allergy.
D. obtaining a liquid-based Papanicolaou (Pap) test.
9. When a critical portion of a population is immunized
against a contagious disease, most members of the
group, even the unimmunized, are protected against
that disease because there is little opportunity for an
outbreak. This is known as _________ immunity.
A. passive
B. humoral
C. epidemiologic
D. community
Answers
1. B. 4. B. 7. A.
2. C. 5. A. 8. B.
3. A. 6. A. 9. D.
1
6042_Ch01_001-024 06/02/17 11:56 AM Page 2
2 CHAPTER 1 ■ Health Promotion and Disease Prevention
Primary prevention measures include activities provided to in-
dividuals to prevent the onset or acquisition of a given disease.
The goal of primary prevention measures is to spare individuals
the suffering, burden, and cost associated with the clinical
condition and primary prevention is the first level of health-
care. An example is health-protecting education and counsel-
ing, such as encouraging the use of car restraints and bicycle
helmets, counseling about safer sexual practices, and providing
information on accident and fall prevention. Given its focus
on preventing illness or injury, primary prevention is usually
viewed as the most effective form of healthcare.
Immunizations and chemoprophylaxis are also examples
of primary prevention measures. Active immunization
through the use of vaccines provides long-term protection
from disease. In herd or community immunity, a significant
portion of a given population has immunity against an infec-
tious agent; the likelihood that the susceptible portion of the
group would become infected is minimized (Fig. 1-1). Passive
immunity is provided when a person receives select antibod-
ies, usually via the administration of immune globulin (IG),
after exposure to an infective agent. This immunity is tempo-
rary and requires the patient to present post-exposure; the
protection provided by IG usually starts within hours of
receiving the doses and lasts a number of months. The use of
vaccines to produce lasting disease protection is preferred to
passive immunization through the use of IG. Another exam-
ple of passive immunity is the acquisition of disease protec-
tion provided from mother to unborn child via the placenta.
Secondary prevention measures include activities provided
to identify and treat asymptomatic persons who have risk
factors for a given disease or in preclinical disease. Examples
include screening examinations for preclinical evidence of
cancer, such as mammography and cervical examination with
a Papanicolaou test. Other examples of secondary prevention
activities include screening for clinical conditions with a pro-
tracted asymptomatic period, such as a blood pressure meas-
urement to detect hypertension and a lipid profile to detect
hyperlipidemia (Table 1-1).
Tertiary prevention measures are part of the management
of an established disease. The goal is to minimize disease-
associated complications and the negative health effects of the
conditions to the patient. Examples include medications and
lifestyle modification to normalize blood glucose levels in
individuals with diabetes mellitus and in conjunction with the
treatment of heart failure, aimed at improving or minimizing
disease-related symptoms.
Discussion Sources
Centers for Disease Control and Prevention. Levels of
prevention. CDC Web site. http://www.cdc.gov/
Features/PreventionStrategy/
National Institute of Allergy and Infectious Disease.
Community immunity. NIAID Web site. https://
www.nih.gov/about-nih/what-we-do/nih-almanac/
national-institute-allergy-infectious-diseases-niaid.
Influenza
Immunization
10. When advising a patient about injectable influenza
immunization, the nurse practitioner (NP) considers
the following about the use of this vaccine:
A. Its use is not recommended in sickle cell anemia.
B. Its use is limited to children older than 2 years.
C. Its use is limited because it contains live virus.
D. Its use is recommended for virtually all members
of the population.
11. A middle-aged man with chronic obstructive
pulmonary disease who is about to receive injectable
influenza vaccine should be advised that:
A. it is more than 90% effective in preventing influenza.
B. its use is contraindicated in the presence of psoriasis
vulgaris.
C. localized reactions such as soreness and redness at
the site of the immunization are fairly common.
D. a short, intense, flu-like syndrome typically occurs
after immunization.
12. A 44-year-old woman with asthma presents asking for a
“flu shot.” She is seen today for an urgent care visit, is
diagnosed with a lower urinary tract infection, and is
prescribed trimethoprim-sulfamethoxazole. She is
without fever or gastrointestinal upset with stable
respiratory status. You inform her that she:
A. should return for the immunization after
completing her antibiotic therapy.
B. would likely develop a significant reaction if
immunized today.
C. can receive the immunization today.
D. is not a candidate for any form of influenza vaccine.
13. Which of the following statements best describes
amantadine or rimantadine use in the care of patients
with or at risk for influenza?
A. Significant resistance to select strains of influenza
limits the usefulness of these medications.
B. The primary action of these therapies is in
preventing influenza A during outbreaks.
C. These therapies are active against influenza A and B.
D. The use of these products is an acceptable alternative
to influenza vaccine.
14. Which of the following statements best describes
zanamivir (Relenza®) or oseltamivir (Tamiflu®) use
in the care of patients with or at risk for influenza?
A. Initiation of therapy early in acute influenza illness
can help minimize the severity of disease when the
illness is caused by a nonresistant viral strain.
B. The primary indication is in preventing influenza
A during outbreaks.
C. The drugs are active only against influenza B.
D. The use of these medications is an acceptable
alternative to influenza vaccine.
Another random document with
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see you till I had written to ask Mrs. Hulme to get your address. How
absurd that would have been to be sure!”
She laughed merrily. Her laugh and voice were both pretty and
musical, and there was an infectious sort of youthfulness about her
—a genuine naïveté—which was not without its charm. She was
small and plump, and still pretty, though no longer young; and
though Eudoxie had considerable difficulty in interpreting her rather
roundabout way of talking, she remained decidedly of opinion that
her soubriquet had been well bestowed.
“I have got some fresh macaroons on purpose for Eudoxie,” said
Mrs. Crichton when she had mastered her visitors’ names in full.
“What a nice confectioner’s there is here! Indeed, the shops are very
good, though my brother feels the want of a library greatly. So kind of
Monsieur Casalis to have sent him those dreadful books.“She eyed
the volumes as she spoke with mingled complacency and aversion.
“That will be some hard work for me,” she said, turning to Cicely with
a smile.
“For you!” exclaimed Cicely in surprise.
“Yes. I have to spell out all manner of things I don’t understand in
the least for Ed—for my brother. He is not allowed to use his eyes in
reading or writing at all yet. To tell you the truth, I was rather pleased
when he was stopped short for want of these books. I am sure he is
beginning to work too hard again; but of course I could not refuse
Monsieur Casalis’s offer of them—so kind. I had the names down on
a bit of paper to try for them at the bookseller’s when he called, you
know. And of course it’s very worrying for a clever person like my
brother to have to be dependent on any one so out-of-the-way stupid
as I am.”
Cicely smiled. “I am sure you are very patient, at any rate,” she
said.
“He is,” said Mrs. Crichton eagerly. “Would you believe it,” she
went on, turning to some papers that lay on a side-table, “I have
three times tried to make a clear copy of these notes and lists—it’s
something botanical—and each time when he has just taken a peep
at it from under his shade, poor fellow, just to make sure it was all
right, he has found some perfectly horrible mistake that could not
possibly be corrected—not to speak of my handwriting, which is
fearful, as you see.” She held out the manuscript to Cicely. “They
have to be in London the end of this week,” she went on in a tone of
despair. “I was just setting to work at them again when you came in;
but it’s no good. I shall never get them done.”
Cicely was examining the papers critically. “Your writing is
perhaps rather too large for this sort of thing—” she began. “I should
think it was—too large and too sprawly and too everything,”
interrupted Mrs. Crichton. It’s dreadful, and so is my spelling. I never
can spell correctly—Wednesday and business and spinach I always
carry about with me in my pocket-book—not that the spelling matters
for these things, as they are all in Latin.”
“I think—you won’t think me presumptuous for saying so, I hope,”
said Cicely “I think I could help you with these, if you like. I have had
a great deal of copying out to do long ago for my father, and I can
write a very clerkly hand when I try. Do you think Mr.—, your brother,
would be afraid to trust me with these papers? I can easily have
them ready for to-morrow’s post, if that will do.”
Mrs. Crichton’s face beamed with delight. “How kind of you—how
very kind of you!” she exclaimed. “I am sure you could do them
beautifully. You look so clever—no, I don’t mean clever. Clever
people are ugly; but you look so wise—dear me!—what can I say?—
that sounds like an owl.”
“Never mind,” said Cicely, laughing. “Will you ask your brother if
he will try me?”
“Of course I will, this very moment,” said the little lady, and off she
went. Within five minutes she returned in triumph. “He is delighted,”
she said. “I knew he would be. He is coming to thank you himself,
and to point out one or two things. He does not like seeing any one
now; his eyes make him feel nervous, poor fellow. He would not
come in to see Monsieur and Madame Casalis yesterday, but he is
so pleased about his papers, he proposed himself to come and
thank you.”
 “I hope it will not annoy him,” said Cicely, a little uneasy at the
idea of the learned man’s personal injunctions. But “Oh! no, he didn’t
mind a bit,” answered Mrs. Crichton in so well assured a tone that
Cicely dismissed her misgivings.
There had certainly been nothing in his sister’s explanation to
make him “mind a bit.”
“There’s a young lady here who would like to do your copying,
Edmond,” had been her very lucid account of Cicely’s offer. “She’s
English, though she’s a niece of that nice old French clergyman who
called yesterday. She looks clever. I am sure she would do it nicely.
She says she is quite accustomed to it.”
“Do you mean that she would do it for nothing?” inquired Mr.
Guildford. “I could not put myself under such an obligation to a
stranger. But perhaps she would let me pay for it. Many poor ladies
make money by copying; and I dare say if she be longs to the family
of a French pasteur, she is not rich. Do you think that she meant that
she would take payment for it?”
“No,” said Bessie doubtfully. “She doesn’t look like that.”
“What does she look like? Is she a governess, or anything of that
kind? What did she say?”
“She only offered out of kindness. She had heard about your
eyes, and I—I told her how stupid I was,” admitted Mrs. Crichton.
“You had much better come and see for yourself, Edmond.”
“Very well—perhaps it would be better. Of course, I should be
very glad to get it well done, if this lady would not be above letting
me pay her,” he said. “But I won’t say anything about that if she looks
like a person that would be offended by such a proposal. I’ll come in
directly; and if I can arrange about it with her, I will show her how I
want it done. But I wish,” he added to himself when his sister had left
him, “I wish Bessie were less communicative to strangers.”
Five minutes later he followed her into the drawing-room. He
came in, expecting to find Mrs. Crichton’s new acquaintance some
insignificant-looking person of the poor lady order, for,
notwithstanding Bessie’s assertion that the pasteur’s niece “did not
look like that,” his mind was prepossessed by its own idea; nor did
he attach sufficient importance to his sister’s judgment to think much
of her description. The light in the room struck upon his eyes
somewhat dazzlingly, for, out of deference to the stranger, he had
taken off the shade he usually wore. The first object he noticed was
Eudoxie seated on a low chair, consuming her cakes with great
equanimity. For a moment he glanced at her in bewilderment. Could
this be his would-be amanuensis? He looked on beyond her to his
sister for explanation, when suddenly from another corner of the
room a third person approached. Had the figure before him been that
of one risen from the dead he could hardly have been more
astonished. Instinctively he lifted his hand to his eyes, as if
suspecting them of playing him false. Was not the light deceiving
him, exaggerating some slight and superficial resemblance into the
likeness of a face whose features he believed would never to him
grow misty or confused—a face he had seen once, long, long ago it
seemed to him now, pale and wistful, with sweet sad eyes, and lips
parted to entreat his help,—the face of Cicely Methvyn as she stood
in the doorway on the night that little Charlie died. He looked again—
the illusion, if such it were, grew more perfect. He felt as if in a
dream—he was turning to seek Mrs. Crichton’s assistance, when
suddenly the spell was broken. The lady came forward quietly and
held out her hand.
“Mr. Guildford,” she said gently, and the slight colour which rose to
her cheeks helped him to realise the fact of her presence, “you did
not expect to see me here, and certainly I did not expect to see you.
How strange it is!”
But he made no movement towards her, he showed no readiness
to take her offered hand.
“Mr. Guildford,” she repeated, in her turn bewildered by a
momentary doubt as to the identity of the man before her with the
owner of the name by which she addressed him, “don’t you know
me?”
Then he started. “I could not believe it,” he exclaimed abruptly.
“You must forgive me, Miss Meth—no, you are not Miss Methvyn
now.”
Cicely’s colour deepened, but she smiled. A pleasant sincere
smile it was, though not without a certain sadness about it too. “Yes,”
she said, “I am. My name is the same any way, though it seems as if
otherwise I must be very much changed.”
He had not yet shaken hands, and as she spoke, Cicely’s arm
dropped quietly by her side. There was a slight inference of reproach
in her tone, and Mr. Guildford was not slow to perceive it.
“I don’t think you are changed,” he said; “I knew you instantly.
That was what startled me so, I was so utterly taken by surprise.”
“Not more than I,” she replied. “I thought you were in India.”
“And I thought you were—” He hesitated.
“Yes,” she said, “I know where you thought I was; but I am not,
you see. That was all changed long ago. Have you heard nothing
about us since you left Sothernshire?” she went on. “Do you not
know that Greystone was sold—that we left it soon after my father’s
death? Do you not know about,” she glanced at her deep mourning
dress, “do you not know that I am quite an orphan now?”
“Yes,” he said in turn; “yes, I know that—I saw it in the ‘Times.’”
His tone was grave and sad. A feeling of self-reproach crept
through him as he recalled the half-bitter sympathy with which he
had seen the announcement of Mrs. Methvyn’s death.
“She has her husband to comfort her,” he had said to himself. For
once, in some fashionable record of “arrivals in town” he had seen
the names of “Mr. and Mrs. Fawcett from Barnstay Castle;” and till
this moment when he met Cicely Methvyn again, a doubt of her
marriage having taken place had never crossed his mind. There fell
a slightly awkward pause. In the presence of a third person, and that
person a stranger, Cicely could not speak to Mr. Guildford of her
mother’s illness and death as she would have liked to do, nor could
he say anything to lead her to do so. At last Bessie came to the
rescue. Amazed by the unexpected discovery of her brother’s
acquaintance with the pasteur’s niece, Mrs. Crichton had been
startled into keeping silence for much longer than was usual with her.
“It is just like a story,” she said to herself in an awe struck whisper.
Suddenly glancing at Mr. Guildford, a new idea struck her, “Oh!
Edmond,” she exclaimed, “you have taken off your shade. Oh! how
very wrong of you, and the light in this room is so strong!”
She darted to the window and began drawing down the blinds.
Mr. Guildford looked annoyed. “It does not matter for a few
minutes, Bessie,” he said.
Cicely glanced at him. There was nothing in the appearance of his
eyes, dark and keen as ever, to suggest injured or enfeebled powers
of sight.
“My eyes are much stronger now,” he said to Cicely. “I strained
them when I was in India, but they are recovering now.”
“I heard that you were over-working yourself,” said Cicely.
“Yes, indeed,” exclaimed Mrs. Crichton. “It was not India, it was
nothing but overwork, and it will be the same thing again if you don’t
take care. He will never be able to use his eyes very much,” she
added, turning to Cicely.
A look of pain crossed Mr. Guildford’s face.
Cicely began to think it true that Mrs. Crichton was “very stupid.”
“Not for a long time, I dare say,” she said quickly. “But I have
always heard that rest does wonders in such cases. And that
reminds me,” she went on, “will you show me exactly how you want
these papers done?”
Mr. Guildford had forgotten all about the papers. Now he looked
up with some embarrassment. “I could not,” he began, but Cicely
interrupted him.
“You thought of letting a stranger do it,” she said. “Why then not
me? I have very little occupation here; it would be a real pleasure to
me.”
She spoke simply but earnestly, and Mr. Guildford made no
further objection. He took up the papers and pointed out Bessie’s
mistakes. Then came a moment in which Mrs. Crichton left the room
in search of another manuscript. Cicely seized the opportunity.
“Mr. Guildford,” she said hastily, in a voice too low to catch the
long ears of the little pitcher in the corner, “I think I had better tell you
that my cousin Trevor Fawcett’s wife is Geneviève Casalis—
Geneviève Fawcett now, of course. It is with her parents I am now
staying here; they are very kind and good. Eudoxie,” with a glance
towards the child, “is Geneviève’s sister. I thought it best you should
know, as I dare say you will see Monsieur and Madame Casalis
sometimes.”
Mr. Guildford did not speak. One rapid glance of inquiry he could
not repress. Cicely stood it with perfect calmness.
“It happened a long time ago, very soon after my father’s death,”
she said quietly. “I—I believed it was for the best then; since, I have
come to feel sure of it.” Here her colour rose a very little. “It was a
comfort to me to be able to devote myself entirely to my mother
when her health failed,” she went on, as if in explanation of her
words; “there was no other tie to interfere.”
Mr. Guildford bowed his head slightly, as if to signify that he
understood. “Thank you for telling me,” he said, as Bessie came in
again.
Cicely was very silent during the walk home, and answered at
random to Eudoxie’s chatter, agreeing with the child’s announcement
that she did not intend to call “him Monsieur Gentil.” “He is not gentil
at all,” she decided, the truth being that Mr. Guildford had not taken
any notice of her, for there was a spice of Geneviève in Eudoxie now
and then after all.
“How strange to have met again here!” Cicely was thinking to
herself. “It is as well, if it was to be, that it happened unexpectedly. It
will prevent his feeling constrained and ill at ease with me on
account of that fancy of his, if indeed he remembers it.”
CHAPTER IX.
 A SOUTHERN WINTER.

“Listen how the linnets sing, Cicely dear;

Watch you where the lilies spring, Cicely sweet.”
* * * * * *
“The lilies shall be for thy brow to wear,
The linnets shall sing of the love I bear.”
Ballad.

NO sooner had the door closed on Cicely and her little cousin than
Mrs. Crichton’s pent-up curiosity broke forth. She overwhelmed her
brother with questions and cross-questions as to the how, where,
and when of his former acquaintance with Miss Methvyn, till Mr.
Guildford was fairly driven into a corner. He defended himself
valiantly for some time; he tried short answers, but even
monosyllables failed in their usually chilling effect on the irrepressible
Bessie. She was not to be snubbed; she only grew increasingly
pertinacious and finally cross.
 “It is too bad of you to be so absurdly reserved with me, Edmond,”
she said at last. “You are not a doctor now; I am not asking you to
gossip about your patients. You will make me suspect something
mysterious if you don’t take care.”
Then Edmond saw that his best policy would be to volunteer as
much information as it suited him that his sister should be in
possession of, knowing by experience that to baffle temporarily her
curiosity was surely to increase it in the end. Hydra-like, it but
sprouted afresh in a hundred new directions, if extinguished in one;
and that she should even suspect the existence of anything he
wished to conceal, with regard to Cicely, was disagreeable and
undesirable in the extreme. So he smiled at her petulant speech, and
answered good-humouredly. “I know what you always mean by
something mysterious, Bessie. You are constantly fancying you have
got on the scent of a love-story. I have no love-story to confide to you
about Miss Methvyn—at least—” he stopped and hesitated.
“At least what?” exclaimed Mrs. Crichton.
“I was thinking,” he said, “of what you said about my not being a
doctor any longer. That does not make me free to gossip about what
I became acquainted with when I was one, does it?”
“No, I suppose not,” said Bessie. “But I shall never tell over
anything about Miss Methvyn. I want to know about her, I have taken
a fancy to her. Do go on after ‘at least.’ ”
“I was merely going to say that the only love-story I can tell you
about her, is painful and must not be alluded to. But under the
circumstances, perhaps, it is best you should know it. When I last
saw Miss Methvyn, she was on the point of marriage with her cousin,
a Mr. Fawcett—the marriage was broken off, and within a very short
time he married another girl—her cousin, but not his, a French girl,
the daughter of these people here, the pasteur and his wife.”
“What a shame!” ejaculated Bessie. “I thought they seemed such
nice people.”
“So they are, I have no doubt. If not, she—Miss Methvyn—would
not be staying with them.”
 “But the girl—their daughter—must have been very designing.”
Mr. Guildford did not answer. “How dreadful for Miss Methvyn!”
continued Bessie. “I wonder it did not break her heart.”
“How do you know it didn’t?” asked her brother quickly.
“She doesn’t look like it,” said Mrs. Crichton. “She looks grave and
rather sad, but she smiles brightly; there is nothing bitter or sour
about her.”
“She has had troubles enough of other kinds to make her grave
and sad. Though, indeed, her face always had that look when in
repose,” he said thoughtfully. “Bessie,” he went on, with a sudden
impulse of communicativeness, born of a yearning for sympathy, “do
you remember one night, nearly two years ago, when I had to go out
into the country beyond Haverstock—a very cold night?”
“Yes,” said Bessie, “I remember it—a little child was very ill. It
died, I think.”
“That night was the first time I saw Miss Methvyn.”—“Standing
with that crimson dress on,” he murmured to himself softly. “Yes,” he
went on aloud, “the child died. He was her nephew. And since then
she has lost father and mother and her home too.”
“Poor girl!” said Mrs. Crichton, with the ready tears in her eyes.
“By the bye,” she added in a brisker tone, “was she Miss Methvyn of
Something Abbey? I never can remember names.”
“Greystone?” suggested her brother.
“Yes, to be sure. I knew it was a colour, black or white or
something. Oh! then, I know about them a little. Some friends of the
Lubecks bought Blackstone, and are living there now. It was sold
because when the father died, they found he had lost a lot of money
—in horse-racing, wasn’t it?”
“Not exactly,” said Mr. Guildford, smiling. “The poor man had been
paralysed for some years. But he did lose money by speculation—
that was true enough. What else did you hear?”
Bessie’s brain was not the best arranged repository of facts in the
world, but by dint of diving into odd corners, and bringing to light a
vast mass of totally irrelevant matter, she managed to give her
brother a pretty clear idea of what she had learnt about the
Methvyns’ affairs. And joining this to what he already knew, Mr.
Guildford arrived at a fair enough understanding of the actual state of
the case. “I don’t believe it was her loss of fortune that separated
them,” he said to himself; “she is not the sort of girl to have allowed
that to influence her. And he—if it had been that—would not have
married a completely penniless girl immediately after. No, it could not
have been that. He must have deceived her—how she must have
suffered! Yet, as Bessie says, I don’t think she does look broken-
hearted.”
He fell to thinking of how she did look. He was silent and
abstracted, but Bessie asked no more questions. Her curiosity was
so far set at rest, but it is to be doubted if her brother’s carefully
considered communicativeness had satisfied her of the non
existence of her “something mysterious.” But she was loyal and
womanly, despite her inquisitiveness; her brother’s secret, if he had
one, was safe.
During the rest of the day, Mr. Guildford was restless and ill at
ease. . He was constantly acting over again the morning’s interview
with Cicely, and wishing that he had said or done differently.
Sometimes it seemed to him that his manner must have appeared
almost rudely repellent and ungracious; at others, he reproached
himself with having behaved with unwarrantable freedom.
“I did not even shake hands with her,” he remembered. “Rude
boor that I am. As if I had any business to annoy her by my absurd
self-consciousness, when she was so sweet and gracious and
unaffected—so evidently anxious to be just as friendly to me as if I
had never made a fool of myself. Of course, it is easy for her to be
unconstrained and at ease with me—there is no reason why she
should not be so—the question is whether I shall ever attain to it with
her.”
Then he grew hot at the thought of having allowed her to copy his
papers—actually to work for him—and ended by saying to himself
that he devoutly wished he had not come into the room, or that,
better still, Bessie had held her silly little tongue about his
occupation. Yet all the time he was looking forward with
unacknowledged eagerness to the next day, cherishing a foolish
hope that Cicely might herself bring back her completed work, or that
possibly she might find it necessary to apply to him for information or
instruction upon some difficult part of the manuscript. And when the
next day came, and the papers, beautifully written, and perfectly
correct, were brought to the Rue St. Louis by old Mathurine, with a
little note from Cicely, hoping that Mr. Guildford would not hesitate to
return them if in any way faulty, he felt a pang of disappointment
which startled him into acute realisation of the fact that he was as
ready as ever, nay, ten times more so, to “make a fool of himself” for
this woman, whom he thought he had grown indifferent to. “It is as if
some one that one had thought dead had come to life again. It is
very hard upon me. For more than a year I have thought of her as
Fawcett’s wife, as more than dead to me, and now the old struggle
must begin again.”
But after a time he grew calmer. The events of the last two years
had altered—some superficial observers might have said, weakened
—this man, once so strong a believer in his own opinion, so
confident in his own power of acting up to it. But if he were
weakened, the weakness was that arising from a greater knowledge
of himself, a juster estimate of human nature, a nobler, because truer
ideal—it was a weakness promising strength. He was less given to
make theories, less loftily determined to live the life he sketched out
for himself. “I am well punished for my presumption in thinking I was
stronger than other men, or that in such strength there was nobility.
Here am I at thirty with powers already curtailed, thankful now not to
be threatened with a future of utter dependence. Here am I who
despised and depreciated woman’s influence—feeling that without
the love of a woman who will never love me, life, in no one direction,
can be other than stunted and imperfect. Yes, I am well punished!”
And it was through this last reflection that he attained to a more
philosophic state of mind. If the disappointment which this love of his
had brought upon him, were a recompense merited by his self-
confidence and self-deception, what could he do but accept it? what
more futile than to waste his strength of mind in going back upon a
past of mistakes and might-have-beens? Why not exert the self-
control he possessed in making the best of what remained, in
enjoying the friendship which Cicely was evidently ready to bestow
upon him, with which, in her altered circumstances, there was little
prospect of any closer tie coming into collision?
“I dare say she will never marry,” he said to himself with
unconsciously selfish satisfaction. “She is not the sort of woman to
‘get over’ such an experience as she has had, in a hurry. I doubt if
she will ever do so. Her very serenity looks as if she had gauged her
own powers of suffering pretty thoroughly, and had now reached a
tableland of calm—I feel sure she will never marry. I should like to
show her that I am able to value her friendship, and that she need
have no fear of my ever dreaming of anything more. I should like her
to respect me.”
So, considerably to Bessie’s surprise, a day or two after the
papers had been despatched, her brother proposed that they should
return Monsieur and Madame Casalis’s call.
“I should like to thank Miss Methryn personally,” he said calmly.
“And I am sure her relations are kind, good sort of people from what
you tell me. It was very civil of them to call. I should not like them to
think me a surly hypochondriac.”
“But are you fit for it?” said Mrs. Crichton, hardly able to believe
her ears.
“Fit to make a call?” he exclaimed, laughing. “Of course I am;
there’s nothing wrong with me now except my eyes, and they are
much better. They never pain me now unless I read or write. I don’t
want to drive there, Bessie,” he went on, “we can walk. It is only two
or three streets off.”
“Very well,” said Bessie, in her heart nothing loth to see
something more of their only acquaintances at Hivèritz. She looked
up at her brother curiously. “I wonder if Edmond has anything in his
head that he hasn’t told me,” she thought. But Edmond met her
glance with perfect self-possession. He felt that he had no motive of
the kind that she evidently suspected; he only wished to return to his
old friendly relations with Cicely Methvyn; there was no fear of
further self-deception. He was satisfied that, having now recovered
from the first surprise of meeting her again, he was in a fair way of
attaining to a composed and comfortable state of mind with regard to
this girl, whose path and his had once more so unexpectedly
crossed each other.
So Bessie was fain to suppose that her discrimination had
actually been at fault, and that her brother was uninfluenced by any
other motives than those he averred. And for some time to come,
there was nothing to disturb her in this opinion. They called on
Madame Casalis, and found both her and Miss Methvyn at home,
and the half-hour spent in the modest little drawing-room in the Rue
de la Croix blanche, was a very pleasant one, and Mr. Guildford
returned home well contented with himself, and satisfied that Cicely
tacitly appreciated his resolution.
“She has great tact,” he thought; “her manner is so simple and
unconstrained that it makes it infinitely easier for me.”
And for her part, Cicely was saying to herself that things were
turning out just as she had hoped—Mr. Guildford had evidently quite
forgotten all about that passing fancy of his; he wished—by his
manner she could see that he wished—to be thoroughly friendly and
kind; he was a man whose friendship any woman might be proud of
possessing. And as she thought thus, there flitted across her mind a
vague recollection of something she had once said to him on this
subject of friendship—it was one summer’s day in the garden at
Greystone—and Mr. Guildford had been expounding for her benefit
some of the wonderful theories which he then believed in so firmly.
She remembered all he had said quite well (how little she suspected
what bombastic nonsense it now appeared to him!), and she
remembered, too, that what she had replied had made him declare
he had converted her. It was something about feeling more honoured
by the friendship than by the love of a man capable of friendship of
the highest kind.
 “I did not say it so plainly,” thought Cicely, “but that was the sense
of it. I know I was rather proud of the sentiment. I wonder if Mr.
Guildford remembers it. I do think him a man whose friendship is an
honour; and it is much better that I should henceforth keep clear of
anything else. I have had storms and troubles enough. Only—only—
sometimes life looks very lonely now.”
But during the remainder of this so-called winter, life passed on
the whole pleasantly enough. The acquaintance between the two
families progressed to friendliness; then to intimacy, till there were
few days when some of their members did not meet. Cicely owned to
herself that the society of the brother and sister added much to the
interest of her otherwise somewhat monotonous life; and Mr.
Guildford, having thoroughly shaken himself free from any possibility
of further self-deception, allowed himself to enjoy Miss Methvyn’s
friendship without misgiving, and day by day congratulated himself
more heartily on the strength of mind with which he had recognised
his position and bravely made the best of it. Only Bessie,
commonplace, womanly, silly little Bessie, sometimes looked on with
vague uneasiness, now and then trembled a little at the thought that
perchance this pleasant present might contain the elements of future
suffering.
“Edmond doesn’t think he is in love with her,” she said to herself,
“and he certainly gives her no reason to think he is. But he has it all
his own way just now; how would it be if some rival turned up all of a
sudden, would not that open his eyes? And though she has been
unlucky once, it is unlikely she will never marry. I could not bear
Edmond to be made miserable. If she were less high-principled and
thought more of herself, I would fear less for him.”
Once or twice there occurred little incidents which increased the
sister’s anxiety, and of one of these she was herself in part the
cause. Little Mrs. Crichton, “stupid” as she called herself, had one
gift. She possessed an unusually beautiful voice. It was powerful and
of wide compass, but above all clear and sweet and true, and with a
ring of youth about it which little suggested her eight-and-thirty years.
She sang as if she liked to hear herself; there was no shadow of
effort or study of effect discernible in the bright, blithe notes, which
yet at times could be as exquisitely plaintive. Cicely, who loved
music more, probably, than she understood it, soon discovered this
gift of her new friend’s, and profited thereby, thanks to Bessie’s
unfailing good-nature, greatly. She was never tired of Mrs. Crichton’s
singing.
“I am glad you like my sister’s voice,” said Mr. Guildford one day,
when Bessie had been singing away for a long time. “I like it better
than any I ever heard, but then I am no judge of music.”
“Nor am I. But in singing one knows quickly what one likes,” said
Cicely. “I have heard a great many voices—some wonderfully
beautiful no doubt, but I never heard one I liked quite as much, or in
the same way, as Mrs. Crichton’s.”
Mr. Guildford looked pleased. “Don’t leave off, Bessie,” he said,
“not, at least, unless you are tired.”
“What shall I sing?” said Bessie, turning over the loose music
lying before her. “Ah! here is one of your favourites, Edmond, though
I don’t think it very pretty. You must judge of it, Miss Methvyn. I have
not sung it lately. Edmond has got tired of it, I suppose. At one time
he was so fond of it, he used to make me sing it half-a-dozen times a
day.”
She placed the song on the desk, and began to sing it before her
brother noticed what she was doing. When he heard the first few
bars, he got up from his seat and strolled to the window, where he
stood impatiently waiting for a pause. Bessie had hardly reached the
end of the first verse before he interrupted her. “I am sure Miss
Methvyn will not care for that song, Bessie,” he exclaimed. “Do sing
something else.”
He crossed the room to the piano, beside which Cicely was
standing, and opened a book of songs which lay on the top. Mrs.
Crichton left off singing, but turned towards her brother with some
impatience. “You are very rude, Edmond,” she exclaimed with half
playful petulance. “You should not interrupt me in the middle of a
song. And you are very changeable—a very few months ago you
thought this song perfectly lovely. Do you like it, Miss Methvyn?” she
inquired, turning to Cicely. “The words are pretty.”
“Are they?” said Cicely, “I don’t think I caught them all. Yes, I think
the song is rather pretty—not exceedingly so.”
“The other verses all end in the same way,” said Bessie, humming
a note or two of the air; “that is the prettiest part, ‘Cicely, Cicely
sweet.’”
Cicely gave an involuntary little start, but she did not speak. Mr.
Guildford turned over the leaves of the book with increasing energy.
“Here, Bessie, do sing this,” he exclaimed, placing another song in
front of the tabooed one on the desk.
“No, I won’t,” said Bessie obstinately, “not till I have finished
Cicely. I can’t understand your being so changeable—it was such a
favourite of yours.”
“One outgrows fancies of the kind,” observed Cicely quietly. “Our
tastes change. I dare say it is a good thing they do.”
“Do you think so?” said Mr. Guildford quickly. “I don’t quite agree
with you. My tastes do not change, and I do not wish them to do so.”
He looked at her as he spoke. Cicely felt her cheeks flush, and
she turned away. Bessie went on singing. By the time the song was
over, Cicely, glancing up again, saw that Mr. Guildford had quietly left
the room.
“How cross Edmond is!” said Bessie, getting up from the piano
pettishly. Suddenly a thought struck her. “Miss Methvyn,” she
exclaimed abruptly, “your name isn’t ‘Cicely,’ is it?”
“Cicely did not immediately answer. “I never thought of it before,”
Mrs. Crichton continued; “it just struck me all at once that I had heard
Madame Casalis call you by some name like it, but she pronounced
it funnily.”
“She very often calls me Cécile,” replied Miss Methvyn quietly.
“But my name is Cicely.”
 Bessie was silent. Then suddenly she turned to Cicely and laid
both hands on her arm entreatingly. “Miss Methvyn,” she said,
“Edmond is like a son to me. I could not bear him to be miserable.
He is not a man to go through anything of that kind lightly. Forgive
me for saying this.”
“There is nothing to forgive,” replied Cicely. “But I think you are
mistaken. Mr. Guildford is not a boy, he is wiser than either you or I.”
Bessie hardly understood these rather enigmatical words, but she
dared say no more. After that day, however, she could never find her
brother’s favourite ballad again; it disappeared mysteriously.
And things went on as quietly as before. Mr. Guildford’s health
seemed perfectly reestablished, and even his eyesight failed to
trouble him. He gave himself a holiday for the remainder of his stay
at Hivèritz, and the days passed only too pleasantly. There were all
manner of simple festivities arranged to amuse their visitor, by the
Casalis family in those days, and in these, Madame Gentille and her
brother were invariably invited to join. There were gipsy parties to the
woods, drives or rides to some of the queer picturesque out-of the-
world villages, which few of the ordinary visitors to Hivèritz cared to
explore; one delightful day spent up in the mountains at Monsieur
Casalis’s little farm. And despite the sorrows, whose traces could
never be effaced, Cicely found life a happy thing at these times and
felt glad that youth had not yet deserted her. She spoke often of her
mother to Mr. Guildford, and in so doing lost gradually the sense of
loneliness which had so sadly preyed upon her. And she listened
with all her old interest to his account of his own hopes and
ambitions, of the studies and research in which he had been
engaged. But whenever he was speaking of himself or his own work,
a slight hesitation, a somewhat doubtful tone struck her which she
could not explain. One day she learnt the reason of it.
They had gone for a long ramble in the woods—Cicely, Eudoxie,
and two of the Casalis boys, and on their way through the town they
fell in with Mrs. Crichton and her brother, who forthwith volunteered
to accompany them. It was March by now, and quite as hot as was
pleasant for walking.
 “It is like English midsummer,” said Cicely, looking up half
longingly into the depth of brilliant blue sky overhead, “only I don’t
think the skies at home are ever quite so blue or the trees and grass
quite so green. The most beautiful English summer day is like to-day
with a veil over it. But I like home best.”

‘Oh! to be in England—’”
“‘Now that April’s there?’”
said Mr. Guildford.
“Yes,” said Cicely.
“Even

‘though the fields look rough with hoary dew?’”

“Yes, I am dreadfully English. I shall never be anything else.”
“I don’t think I care particularly where I am,” said Mr. Guildford, “if I
have plenty to do.”
“And you always will have that,” said Cicely.
“I don’t know,” replied he. They had walked on a little in front of
the others; there was no one to overhear what was said. “There will
always be plenty for me to do, certainly, but whether I shall be able
to do it is a different matter.”
His tone was desponding.
“How do you mean?” said Cicely quickly. “Are you afraid about
your eyes?”
“Yes,” he said. “I can’t bear to say it, but I don’t think I mind your
knowing. I am afraid I shall never have very much use of my eyes.
With care I may keep my sight, but I shall never be able to do half I
should otherwise have done.”
Cicely was silent for a few moments. Then, “I am so sorry,” she
said simply. But that was all, for Eudoxie came running up, begging