ch 29 Child With a Genitourinary Condition

A practicing nurse explains to a nursing student that which is the most common cause of acute renal failure in children? A. Congenital renal problems B. Glomerulonephritis C. Hemolytic uremic syndrome D. Tylenol (acetaminophen) overdose

ANS: C Hemolytic uremic syndrome is most often associated with children eating undercooked meat and is the most common cause of acute renal failure in the pediatric population. Tylenol overdose is associated with liver failure.

A 6-year-old child is scheduled for a voiding cystourethrogram. Which action by the nurse is the most appropriate? A. Ask the parents about shellfish or iodine allergies. B. Give the child a preprocedure cleansing enema. C. Instruct the parents to give the child clear liquids afterward. D. Provide developmentally appropriate teaching.

ANS: A Because this test uses iodinized contrast material, it is important to assess for allergies to this substance or to iodine, which is often found in shellfish. Teaching would be provided but does not take priority over this important safety measure. There is no need for an enema. After the procedure, the child resumes a normal diet.

A nurse is assigned to care for four children who have acute kidney injury (AKI). Which child should the nurse see first after obtaining the handoff report? A. Anuric B. Oliguric C. Has deep, rapid respirations D. Having in-room dialysis

ANS: A Children with AKI generally are not anuric unless a catastrophic event has occurred. The nurse needs to see this child first. Oliguria (low urine output) is an expected finding unless the child is in the diuretic phase (high-output phase) of AKI. Deep rapid respirations (Kussmaul's respirations) are also expected as a compensatory response to the metabolic acidosis of AKI. A child receiving dialysis in the room is being attended to by a dialysis nurse.

A child is prescribed gentamycin (Garamycin) and develops acute kidney injury. Which etiology is the most likely cause of the child's acute kidney injury? A. Intrarenal B. Postrenal C. Prerenal D. Streptococcal

ANS: A Gentamycin is one of the aminoglycoside antibiotics, which are known to be nephrotoxic, leading to intrarenal kidney injury. Prerenal kidney injury is due to decreased perfusion. Postrenal kidney injury is obstructive in nature. Strep infections can cause damage to body systems, but there is no indication this child had a strep infection. Gentamycin is directly related to an intrarenal injury.

A child has acute kidney injury following a serious motor vehicle crash. Which intervention takes priority? A. Administer IV fluids and blood products. B. Insert an indwelling urinary catheter. C. Monitor hourly urine output measurements. D. Place the child on a low-sodium diet.

ANS: A Hypovolemia, blood loss, and shock all can lead to prerenal kidney injury. The priority interventions include administering fluids and blood products if needed. An indwelling urinary catheter will be important for hourly urine output measurements, but this will not actively help the problem. A low-sodium diet may or may not be appropriate.

A child has acute kidney injury (AKI). Which primary acid-base balance does the nurse assess the child for? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

ANS: A In AKI there is insufficient hydrogen ion excretion and poor bicarbonate reabsorption, leading to metabolic acidosis.

An adolescent patient with acute kidney injury (AKI) asks why she is taking Tums (calcium carbonate). Which response by the nurse is the most appropriate? A. Gets rid of phosphorus B. Prevents Curling ulcers C. Prevents gastric reflux D. Provides calcium

ANS: A In AKI, phosphorus is high, and patients are given phosphorus binders, such as Tums. They are not used to prevent reflux or Curling ulcers (seen in burns), or to provide calcium.

The parents of a child diagnosed with vesicoureteral reflux (VUR) want to know why their child's kidneys appear large on an abdominal x-ray. Which response by the nurse is the most appropriate? A. Enlarged due to urine backup B. Genetic defect causing VUR C. Multiple tumors D. Unrelated finding

ANS: A In VUR, urine backflows into the kidneys, causing hydronephrosis, or distention of the kidneys. The other answers are incorrect.

An adolescent on the cross-country track team had a urinalysis during a school physical that showed proteinuria. Which action by the nurse is the most appropriate? A. Advise the teen not to run for 48 hours and repeat the test. B. Collaborate with the provider to order kidney imaging tests. C. Explain the finding is insignificant and does not need follow-up. D. Take the teen's blood pressure on three separate occasions.

ANS: A Proteinuria can be a benign finding, especially if it is noted after heavy exercise or fever. The teen should avoid exercise for 48 hours and repeat the test. At this point, further testing is not warranted.

A child is being treated for nephrotic syndrome. Which assessment finding indicates that an important goal for this child is being met? A. Decreased abdominal girth B. Diminished urine output C. Improved rash D. Increased weight over a week

ANS: A The combination of fluid retention and protein loss through the urine produces ascites, or a swollen belly. Decreasing abdominal girth signifies that the disease is being successfully treated. Urine output is already diminished in nephrotic syndrome. There is no rash. Increasing weight means increased fluid retention, which would not be an improvement.

The pediatric clinic nurse calls a parent to report urinalysis findings for her child including microscopic hematuria. Which question by the nurse is most appropriate? A. "Has your child recently had strep throat?" B. "Has your child been in a bike or car crash?" C. "Has your child started menstruating yet?" D. "Has your child taken lots of bubble baths?"

ANS: A The most common causes of microscopic hematuria include UTI, poststreptococcal glomerulonephritis, hypercalciuria, and structural abnormalities. Trauma would more likely cause gross hematuria. The other two questions are appropriate depending on the age and sex of the child, but do not assess for the most common reasons for this finding.

A child is brought to the pediatric clinic, where the parent reports that the child has tea-colored urine and puffy eyes. Which diagnostic test does the nurse prepare the parent and child for based on the assessment findings? A. BUN and creatinine B. Intravenous pyelogram C. Suprapubic aspiration D. Voiding cystourethrogram

ANS: A This child has manifestations of possible glomerulonephritis. To assess kidney function, the patient needs a BUN and creatinine. A pyelogram is used when kidney stones are suspected. Suprapubic aspiration is one way of collecting a sterile urine sample, but is very invasive. A voiding cystourethrogram is used to assess for reflux.

The nurse is planning discharge teaching for a child who just had a kidney transplant. Which information does the nurse provide regarding signs of rejection? (Select all that apply.) A. Decreased urine output B. Edema C. Fever D. Pain over the kidney E. Weight loss

ANS: A, B, C, D Decreased urine output, edema, fever, and pain over the donor kidney site are all signs of possible rejection. The child would have a weight gain related to the edema.

The student studying the renal system learns that the kidneys have several functions. Which options are functions of the kidneys? (Select all that apply.) A. Filtering the blood B. Maintaining electrolyte balance C. Regulating acid-base balance D. Removing waste products E. Suppressing hormone release

ANS: A, B, C, D Functions of the kidneys include filtering the blood, removing waste products from the blood, regulating both fluid and electrolyte and acid-base balance, and releasing hormones.

A faculty member is explaining complications of hemodialysis to a group of students. Which complications does the faculty member include in the discussion with the students? (Select all that apply.) A. Bleeding B. Febrile reactions C. Hypotension D. Infection E. Pulmonary embolism

ANS: A, B, C, D There are many complications associated with hemodialysis, including bleeding, febrile reactions, hypotension, and infection. Although any ill child can develop a pulmonary embolism, this is not a specific complication of this therapy.

The student learns that which hormones are regulated by the kidneys? (Select all that apply.) A. Calcitriol B. Creatinine C. Estradiol D. Erythropoietin E. Renin

ANS: A, B, E Hormones released by the kidneys include calcitriol, erythropoietin, and renin. Creatinine is a laboratory value that measures kidney function. Estradiol is a hormone but is not released by the kidneys.

A new mother asks the nurse why babies are more prone to dehydration than adults. Which rationales from the nurse best answer this mother's question? (Select all that apply.) A. A greater body surface area than adults B. Higher percentage of total body water C. Improved ability of kidneys to concentrate urine D. Kidneys too efficient in excreting waste E. More fluids losses through GI tract and skin

ANS: A, B, E There are several reasons children are more prone to dehydration than adults, including: a greater body surface area from which to lose fluids, a higher percentage of total body water, more losses from the GI tract and skin, a decreased ability of the kidneys to concentrate urine, and immature kidneys that are not good at excreting waste products.

A nurse is providing teaching on toilet training to a parent education group. Which signs of training readiness does the nurse explain to the parents? (Select all that apply.) A. Can stay dry for at least 2 hours B. Gets up by self at night for toileting C. Showing interest in toileting D. Tells parent of need to use toilet E. Wants to hold urine and not void

ANS: A, C, D There are several "readiness" signs to watch for when planning toilet training. These include being able to stay dry for a specific amount of time, showing interest in toileting, and being able to tell the parent or caretaker of the need to use the toilet. Getting up by oneself and wanting to hold the urine are not signs.

The nurse is explaining the RIFLE classification of kidney injury to a student. Which options are included in this system? (Select all that apply.) A. End-stage kidney disease B. Failure to concentrate urine C. Injury to the kidney D. Loss of protein in the urine E. Risk of renal dysfunction

ANS: A, C, E RIFLE stands for risk of renal dysfunction, injury to the kidney, failure of the kidney, loss of kidney function, and end-stage kidney disease.

A child has just returned to the pediatric intensive care unit after having a kidney transplant. Which assessment takes priority for this child? A. Level of consciousness B. Hourly urine output C. Pain D. Vital signs

ANS: B All assessments are important in a postoperative patient. However, because the child had a kidney transplant, assessment of renal function takes priority.

A child is admitted to the hospital with suspected hemolytic uremic syndrome (HUS). Laboratory results indicate elevated BUN, creatinine, and potassium. Which action by the nurse takes priority? A. Administer antibiotics. B. Apply cardiac monitoring. C. Insert a urinary catheter. D. Obtain a stool sample.

ANS: B An elevated potassium can cause serious, even fatal, dysrhythmias. The nurse applies cardiac monitoring first for patient safety. Inserting a urinary catheter and sending a stool sample are appropriate but do not take priority. Antibiotics are not given in HUS because they exacerbate the condition.

The parents of a child with chronic kidney disease ask the nurse why the child is prescribed epoetin alfa (Epogen). Which response by the nurse is the most accurate? A. "It binds with and removes phosphorus." B. "It will help his body to make more red blood cells." C. "It will help to boost his white blood cell count." D. "It will help his body to make more platelets so he doesn't bleed."

ANS: B Anemia is common with chronic kidney disease due to reduced erythropoeitin, which is vital for making red blood cells. The other answers are incorrect.

An acutely ill child is admitted for a suspected severe urinary tract infection (UTI). Which is the priority action by the nurse? A. Administer broad-spectrum antibiotics as ordered. B. Obtain a urine sample for culture and sensitivity. C. Start an IV line for aggressive fluid resuscitation. D. Teach the parents how to prevent future UTIs.

ANS: B Antibiotics need to be started as soon as possible, but it is imperative to obtain a urine sample for a culture and sensitivity to guide medication choices first. While awaiting the results, the nurse will administer a broad-spectrum antibiotic. The child does need an IV, but there is no indication that the child needs aggressive fluid resuscitation. Teaching is always an important task, but does not take priority over obtaining the sample for urinalysis.

A child is in the emergency department following a car crash. Which finding noted by the nurse warrants immediate intervention? A. Complains "I hurt all over." B. Grey-Turner's sign C. Increased WBCs D. Tachycardia

ANS: B Grey-Turner's sign is bruising in the flank area and can indicate a renal injury. The other signs would be expected after a traumatic event.

An infant has poor feeding, fever, and malodorous urine. The parents do not want the nurse to catheterize the child. Which response by the nurse is the most appropriate? A. Apply a urine collection bag on the baby. B. Explain how this procedure obtains the best results. C. Give the baby acetaminophen (Tylenol) for fever. D. Inform the health-care provider of the refusal.

ANS: B Parents can be understandably distraught at the thought of their baby having an invasive procedure. The nurse should ensure that the parents understand why the catheterized urine sample or a suprapubic aspirated urine sample is the best choice for obtaining the most accurate urinalysis results. If the parents still refuse, the nurse should document their refusal, inform the provider, and apply a collection bag. The nurse should also treat the baby's fever with acetaminophen, but this option is not directly related to the question.

A child presents to the pediatric clinic, where the parent reports that the child has had bloody diarrhea and joint pain. Which diagnostic test does the nurse prepare the child and parent for first? A. Echocardiogram B. Skin assessment C. Serum renal studies D. Urinalysis

ANS: B The classic signs of Henoch-Schönlein purpura are rash, gastrointestinal complaints (often bloody diarrhea), hematuria, and arthritis. The nurse needs to assess the child's skin for a rash. The diagnosis is usually made by clinical findings, as there is no specific diagnostic test.

A school-age child has renal disease and the parent wants to know how this could cause the child's hypertension. Which response by the nurse is the most appropriate? A. "The high blood pressure caused the kidney disease." B. "The kidneys regulate renin, which controls blood pressure." C. "The medication your child takes often raises blood pressure." D. "The renal diet includes a lot of sodium, which raises blood pressure."

ANS: B The kidneys regulate renin, a hormone that controls blood pressure. Kidney abnormalities often affect renin, leading to hypertension. In a child this young, the kidney disease most likely came first; in adults, long-standing hypertension is a frequent cause of renal disease. Medications are not the reason. The typical renal diet is low in sodium.

An infant appears dehydrated. Laboratory results indicate a serum sodium of 143 mEq/L. Which fluid would the nurse use for IV replacement? A. 0.45% normal saline B. 0.9% normal saline C. 3% normal saline D. D5W with 20 mEq KCL

ANS: B This child has an isotonic dehydration, in which fluids and solutes are lost in balanced proportions, as evidenced by the normal serum sodium level. The child needs an isotonic IV solution, which would be 0.9% normal saline. The 0.45% normal saline ("half normal saline") is hypotonic, as is D5W, with or without potassium. The 3% normal saline is hypertonic.

A nurse is explaining to a group of students that there are certain criteria that are met before a child starts renal replacement therapy. Which of the following criteria does the nurse include in the discussion with the students? (Select all that apply.) A. Acidosis with pH < 7.2 or rising rapidly B. BUN > 150 mg/dL, or lower if rising rapidly C. Mental status changes from uremia D. Potassium > 6.5 mEq/L despite treatment E. Presence of dialyzable toxins or poisons

ANS: B, C, D, E There are several criteria for beginning renal replacement therapy, including those listed here. Acidosis with a pH of greater than 7.2 or HCO3 greater than 10 mEq/L are also criteria, but if the pH is rising (normalizing) quickly, that would not be an indication to begin therapy.

A child is receiving hemodialysis. The parents ask why hypotension is a possible complication. Which response by the nurse is the most appropriate? A. "It could be from the anticoagulant we use." B. "Kidney disease can often cause hypotension." C. "The treatment is removing fluid from his body." D. "Your child is critically ill and is unstable."

ANS: C Hemodialysis removes fluid from the child's body, sometimes at a rate that causes hemodynamic instability, including hypotension. The other answers are not accurate.

A nurse is caring for a child who is scheduled for a kidney biopsy. The prebiopsy laboratory results indicate a platelet count of 88,000, pH of 7.28, and potassium of 5.8 mEq/L. Based on these laboratory results, which action by the nurse is the most appropriate? A. Ensure signed consent is on the chart. B. Document the findings in the chart. C. Notify the provider immediately. D. Prepare to administer Kayexalate (sodium polystyrene).

ANS: C A platelet count this low is too low to perform an invasive procedure, such as a kidney biopsy. The nurse should notify the provider immediately. Documentation should be done and consent should be on the chart prior to a procedure, but in this case, the biopsy may be postponed. The potassium level is slightly high and probably does not warrant Kayexalate, but in any event, notifying the provider takes priority.

A nurse is caring for a child with acute kidney injury (AKI) at home. The child's laboratory work is as follows: serum albumen 2.8 g/dL and serum protein 4 g/dL. Which action by the nurse is the most appropriate? A. Assess the child for edema. B. Document findings in the chart. C. Facilitate a dietitian referral. D. Weigh and measure the child.

ANS: C All interventions are appropriate for a child with AKI. However the child's laboratory results indicate malnutrition, and with the dietary restrictions the child must follow, ensuring adequate nutrition is difficult. A referral to a dietitian is most important.

A 5-year-old child has enuresis. Which medication regime does the nurse educate the parents on related to this diagnosis? A. Imipramine (Tofranil), 10 mg before bed B. Imipramine (Tofranil), 25 mg before bed C. Oxybutynin chloride (Ditropan), 5 mg once daily D. Oxybutynin chloride (Ditropan), 50 mg once daily

ANS: C Both medications are used in this condition. Tofranil cannot be used in children under the age of 6. The dose of Ditropan is 5 mg once daily and can be titrated upward to a maximum dose of 20 mg/day.

A school-age boy is in the emergency department with testicular torsion. Which action by the nurse takes priority for this patient? A. Administer prophylactic antibiotics. B. Assess and treat the child's pain. C. Ensure surgical consent is on the chart. D. Ice and elevate the scrotum.

ANS: C Testicular torsion is a surgical emergency, and the nurse's priorities are to facilitate surgery. The nurse must ensure a signed consent is on the chart. Treating pain is important too, but the consent is a legal requirement. Prophylactic antibiotics may or may not be given. Ice and elevation may be helpful as a comfort measure, but do not take priority over the consent.

The nurse is assisting a 12-year-old kidney transplant recipient to select items from the hospital menu. Which meal indicates an appropriate understanding of dietary restrictions? A. Chicken alfredo, breadstick B. Cheese pizza, fruit cocktail C. Lasagna, salad, breadstick D. Pasta with tomato sauce, salad

ANS: D A kidney transplant recipient is placed on a protein-restricted diet. Pasta with plain tomato sauce is the lowest-protein menu item listed. The other meals are high in protein. Sodium may be limited too.

An adolescent male patient had an orchiopexy for cryptorchidism as an infant. Which health promotion activity does the nurse educate this patient about? A. Annual digital prostate exam B. Fertility testing C. Genetic screening D. Testicular self-exam monthly

ANS: D After orchiopexy, the teen still has a high risk for testicular cancer and should perform testicular self-exams each month. The other actions are not warranted for this condition.

A school-age female child has a urinary tract infection (UTI). The culture has come back positive for Escherichia coli. Which teaching measure is most important for the nurse to include in the teaching plan? A. Avoid bubble baths and nylon panties. B. Offer the child fluids frequently. C. Place the child on a voiding schedule. D. Teach the child to wipe from front to back.

ANS: D All items are appropriate to teach when a child has a UTI. However, E. coli infection stems from contamination with fecal material. The female child should be taught to wipe from front to back to prevent this cross-contamination.

A student nurse wants to know why a bruit is heard and a thrill palpated at the site of an AV fistula used for dialysis. Which response by the nephrology nurse is the most appropriate? A. Abnormal findings signaling complications B. Flapping of the AV valve during circulation C. Small blood clots blocking some blood flow D. Turbulent blood flow through the fistula

ANS: D Blood flowing through an AV fistula goes from a high-pressure system into a low-pressure system during circulation, leading to turbulent flow. It is a normal finding and not caused by the AV valve or small blood clots.

A child is receiving home peritoneal dialysis. When the visiting nurse assesses the patient, he finds the outflow from the dialysis to be cloudy. Which action by the nurse is the most appropriate? A. Call 911 and send the child to the hospital. B. Call the nephrology clinic to make an appointment. C. Review teaching with the child on the process. D. Take a full set of vitals and notify the provider.

ANS: D Cloudy outflow could indicate peritonitis, a serious complication of peritoneal dialysis. The nurse should take a full set of vitals to assess for infection and call the provider. The child does not need 911. Teaching can be done later. The child should not wait for an appointment.

A nurse is obtaining a bagged urine collection on an infant. Which action by the nurse is most important? A. Clean and powder the skin prior to bagging. B. Remove the bag as soon as it contains urine. C. Send the sample to the laboratory as soon as possible. D. Use universal precautions, including gloves.

ANS: D For infection control, the nurse uses universal precautions, including wearing gloves when collecting urine samples. The baby's skin should be clean and dry; powder will cause the bag to not adhere. The other answers are appropriate, but infection control and safety come first.

A child has glomerulonephritis and hypertension. Which dietary modification is most appropriate for the nurse to suggest? A. High fiber B. High potassium C. Low saturated fat D. Low sodium

ANS: D Hypertension in glomerulonephritis is usually due to fluid overload, and a sodium-restricted diet can help this problem. If the patient is on loop diuretics (often prescribed for hypertension in these patients), potassium is important. High fiber and low saturated fat are healthy diets for nearly everyone.

An infant is born with exstrophy of the bladder but otherwise appears healthy. Which nursing diagnosis is the priority for this infant? A. Altered family processes B. Fluid volume deficit C. Hypothermia D. Risk for infection

ANS: D In this condition, the bladder is open on the abdominal wall, and priority interventions revolve around preventing infection. There is no indication that the child has fluid volume deficit or hypothermia. Altered family processes might be a diagnosis, but physical diagnoses take priority over psychosocial ones.

A child is hospitalized with acute kidney injury (AKI) and has a critical hyperkalemia. Which order would the nurse question as inappropriate for this child? A. Calcium gluconate B. Dextrose and insulin C. Emergent dialysis D. Kayexalate (sodium polystyrene) enema

ANS: D Kayexalate enemas can take up to 4 hours to work. With critical hyperkalemia, the drug of choice needs to work faster than this. The other options would all work faster.

A nurse is preparing to administer gentamicin (Garamycin), IV, to a hospitalized child. Before administering the medication, the nurse checks the drug trough level, which is 13 µg/mL. Which action by the nurse is the priority for this child? A. Administer the medication. B. Document the findings. C. Have the laboratory re-run the specimen. D. Notify the health-care provider.

ANS: D This trough level is too high (normal is 2 µg/mL). Because this drug is nephrotoxic, care must be given to avoid causing acute kidney injury. The nurse notifies the health-care provider about the results and does not administer the medication. Documentation should occur, but is not the priority. Asking the laboratory to re-run the specimen is not warranted.