Assessment of the Renal/Urinary System

A patient has returned from a captopril renal scan. Which teaching does the nurse provide when the patient returns?

"Arise slowly and call for assistance when ambulating." Captopril can cause severe hypotension during and after the procedure, so the patient should be warned to avoid rapid position changes and about the risk for falling as a result of orthostatic (positional) hypotension.

Which parameter would assess acid-base balance in a patient?

Bicarbonate level. Assessing the bicarbonate levels in a patient would assess acid-base balance in a patient because bicarbonate reabsorption in the kidneys maintains acid-base balance. Sodium helps to maintain fluid balance. Calcium controls calcium balance. Potassium maintains fluid volume and osmolarity.

The urinalysis report of a patient reveals high specific gravity. What can be the probable cause of this finding?

Dehydration Specific gravity is the concentration of particles in the urine. Dehydration results in concentrated urine that increases the specific gravity of urine, while high fluid intake decreases the specific gravity of urine.

What urinary changes does the nurse expect in a patient with an enlarged prostate?

Difficulty in starting the urine stream The patient with an enlarged prostrate has difficulty in starting the urine stream and may develop urinary retention, which may result in a urinary tract infection.

When planning an assessment of the urethra, what does the nurse do first?

Don gloves Before examination begins, body fluid precautions (gloves) must be implemented first. Examining the meatus, noting unusual discharge, or recording the presence of abnormalities are things that the nurse should do after putting on gloves.

A patient reports discomfort and pain when voiding. How does the nurse document this finding?

Dysuria Discomfort and pain associated with voiding is known as dysuria and is associated with urinary retention or urinary tract infection. The condition in which the total urine output is less than 100 mL in 24 hours is known as anuria. When total urine output is between 100 and 400 mL in 24 hours, the condition is known as oliguria. Polyuria is increased urine output, usually greater than 2000 mL in 24 hours.

Which laboratory test is the best indicator of kidney function?

Creatinine Creatinine excretion, the end product of muscle metabolism, remains relatively steady and therefore is the best indicator of renal function. BUN may be affected by protein or fluid intake.

What finding in a patient's urinalysis does the nurse identify with early stage kidney disease?

Microalbumin Microalbuminuria is the presence of albumin in the urine. Microalbumin levels greater than 20 mg/mmol for men, and greater than 28 mg/mmol for women, indicate early stage kidney disease, especially in the patient with diabetes.

A nurse is caring for a patient who is being treated for acute kidney failure. What response made by the nurse is the best way to assess the patient's history of hypertension?

"Have you ever been told your blood pressure is high?" Asking the patient, "Have you ever been told your blood pressure is high?" prompts the patient to tell the nurse about any past history of hypertension. Asking the patient, "Do you have high blood pressure?" is appropriate; however, this question is not the best way to assess the patient's history of hypertension because the patient may not know what high blood pressure is.

Which instruction does the nurse give a patient who needs a clean-catch urine specimen?

"Do not touch the inside of the container." A clean-catch specimen is used to obtain urine for culture and sensitivity of organisms present; contamination by the patient's hands will render the specimen invalid and alter results. After cleaning, the patient should initiate voiding, then stop and resume voiding into the container. Only 1 ounce (30 mL) is needed; the remainder of the urine may be discarded into the commode.

Which diagnostic test is safe for patients with kidney failure to determine the functional ability of the kidney?

Nuclear renal scan A nuclear renal scan is used to provide functional information of the kidney in patients with kidney failure. It does not expose patients to iodinated contrast dye, which can increase risk for further kidney damage.

A nurse is providing discharge instructions for a patient with acute kidney failure. What question by the nurse best assesses the patient's understanding of the condition?

"Can you tell me what happens with your condition?" The question, "Can you tell me what happens with your condition?" prompts the patient to tell the nurse his understanding of the condition in his own words. The nurse can then determine how effective the teaching has been. The questions, "What medications did the doctor prescribe?" "Do you understand what condition you have?" and "Can you tell me if you are allergic to any medications?" are closed-ended questions that do not prompt the patient to elaborate on his condition and are not the best questions to assess the patient's understanding of the condition.

A nurse is assessing a patient prior to the patient undergoing a radiological exam with injected contrast dye. The patient tells the nurse, "I think I had a reaction to the dye the last time I had this procedure done." What is the nurse's best response?

"What kind of reaction did you experience?" Once the nurse determines that the patient may be allergic to contrast dye, the next important step is to find out what type of reaction the patient had to the dye. This will let the nurse know the severity of the reaction and notify the patient's physician regarding the reaction.

During a health fair, the primary health care provider selected a few patients who are suspected to have kidney disease for further screening. What are the probable selection criteria? Select all that apply

A 40-year-old patient with diabetes. A 45-year-old patient with polycystic kidney disease. A 55-year-old patient with a sudden onset of hypertension. A 40-year-old patient with diabetes has an increased risk for developing kidney disease since diabetes is a chronic illness. A 45-year-old patient with polycystic kidney disease may have a possibility of acquiring kidney disease. There is a possibility of kidney disease in patients with a sudden onset of hypertension.

Which factor may cause nephrogenic systemic fibrosis?

Exposure to gadolinium-enhanced MRI

The nurse suspects gastrointestinal (GI) bleeding in a 62-year-old patient with kidney disease. Which finding in the patient's blood report supports the nurse's suspicion?

Blood urea nitrogen (BUN) value of 25 mg/dL The normal range of BUN in an older adult is 8-23 mg/dL. An increased BUN level in the patient may indicate GI bleeding.

What does the nurse expect the health care provider to prescribe for a patient before a percutaneous kidney biopsy?

Coagulation tests The health care provider prescribes coagulation studies such as platelet count, activated partial prothrombin time, and bleeding time, all of which are performed before surgery because of the risk of bleeding.

The nurse is assessing a pregnant woman suspected to have kidney disease. Which assessment findings by the nurse would help in the diagnosis?

Increased protein levels in the urine Increased protein levels in the urine indicate proteinuria. This laboratory assessment indicates kidney disease.

Which condition would the nurse suspect in a patient whose laboratory results show a serum creatinine level of 1.8 mg/dL?

Kidney impairment An increased level of serum creatinine indicates kidney impairment. Normal creatinine for a male is 0.6-1.2 mg/dL and a female is 0.5-1.1 mg/dL.

For which patients scheduled for a computed tomography (CT) with contrast does the nurse communicate safety concerns to the health care provider? Select all that apply.

Patient with an allergy to shrimp Patient with a history of asthma Patient with a blood urea nitrogen (BUN) of 62 mg/dL and a creatinine of 2.0 mg/dL Patient who took metformin 4 hours ago The patient who will be undergoing a CT with contrast should be asked about known hay fever or food or drug allergies, especially to seafood, eggs, milk, or chocolate. Contrast reactions have been reported to be as high as 15% in these patients. Patients with asthma have been shown to be at greater risk for contrast reactions than the general public. When reactions do occur, they are more likely to be severe. The risk for contrast-induced nephropathy is increased in patients who have pre-existing renal insufficiency (e.g., serum creatinine levels greater than 1.5 mg/dL or estimated GFR <45 mL/min). Metformin must be discontinued at least 24 hours before and for at least 48 hours after any study using contrast media because the life-threatening complication of lactic acidosis, although rare, could occur. There are no contraindications to undergo CT with contrast while taking morphine sulfate. CT with contrast may help to identify the underlying cause of pain.

While reviewing the urinalysis report of a patient, the nurse suspects that the patient has a urinary tract infection. Which findings support the nurse's conclusion?

Presence of nitrites The presence of nitrites in the urine is indicative of a urinary tract infection. The presence of crystals in the urine indicates that the specimen has been allowed to stand. The presence of ketones in the urine is indicative of diabetic ketoacidosis or prolonged fasting or anorexia nervosa. The presence of red blood cells in the urine can occur normally with catheterization, stones, or glomerular disorders.

A nurse is caring for a patient who has developed glomerulonephritis after a streptococcal infection. What laboratory test result will the nurse use as the best indicator for the patient's kidney function?

Serum creatinine Serum creatinine is produced when muscle and other proteins are broken down. Because protein breakdown is usually constant, the serum creatinine level is the best indicator of kidney function.

The nurse is caring for a patient with kidney disease whose glomerular filtration rate (GFR) is recorded to be 45 ml/min. What is the best nursing intervention in this situation?

To maintain an adequate fluid intake A normal GFR is 120 ml/min for a healthy young adult and 65 ml/min for an older adult. A decrease in the kidney's GFR may indicate a decrease in the ability to regulate water balance. The kidneys are less able to conserve water, so fluid intake should be adequate. In this situation, the nurse may act first and notify primary health care provider later.

A nurse is performing an assessment on a patient with an alteration in renal function. What patient statements does the nurse recognize as potential contributing factors to the patient's current condition? Select all that apply.

"I sometimes huff paint with my friends." "I sometimes use heroin during the week." "I smoke meth, but only on the weekends." Exposure to volatile solvents, such as inhaling paint fumes, can lead to renal damage. Additionally, use of heroin and methamphetamines has also been associated with kidney damage.

A nursing student is caring for a patient who has been diagnosed with nephritis. The nursing student asks the nurse preceptor what the difference is between nephritis and nephrosis. What is the nurse preceptor's best response?

"Nephritis is the inflammation of the kidney and nephrosis is the degeneration of the kidney." Though these terms may have been used interchangeably in the past, there are significant differences between these terms.

An occupational nurse is caring for a patient who works at an oil refinery and has a recent history of renal impairment. What statement made by the nurse is appropriate regarding occupational hazards and risk of renal impairment?

"Try to avoid direct contact of oil with your skin or mucous membranes." Exposure to hydrocarbons in oil may be the cause of the patient's renal impairment. The nurse should teach the patient to avoid direct contact with his or her skin or mucous membranes. It is not appropriate for the nurse to tell the patient to find alternative employment. While instructing the patient to wash his or her hands is generally appropriate, to suggest this after the patient has been exposed to oil is not appropriate. Instead, the nurse would instruct the patient to follow his or her employer's procedures when exposed to a potential hazardous material. Instructing the patient to avoid being within 50 feet of a potential chemical is not appropriate instruction because each chemical has its own safety precautions and the nurse would not generally suggest this.

A nurse is caring for a patient who will undergo a kidney, ureter, and bladder x-ray (KUB) procedure. What statement by the nurse is appropriate when teaching the patient about the procedure?

"You do not need any special preparation for this test." The kidney, ureter, and bladder x-ray (KUB) procedure is a plain film of the abdomen obtained without any specific patient preparation.

A novice nurse is working on a renal unit and has four patients who require computed tomography (CT) scans with contrast dye. Which patient does the nurse identify as having the highest risk for developing acute kidney failure due to the contrast dye?

65-year-old female with a history of type 2 diabetes The contrast dye used with certain computed tomography (CT) scans may be nephrotoxic, or damaging the kidneys. The risk of this occurring is greatest among patients who are older, dehydrated, or have previous kidney dysfunction. The 65-year-old female patient with a history of type 2 diabetes is an older adult and may have kidney dysfunction.

Which physiological abnormality in kidney function can be detected by x-rays?

Calcification An x-ray shows calcifications and gross anatomical features in a patient with kidney disease. The extent and spread of tumors in the kidneys is observed through magnetic resonance imaging. Polycystic disease can be detected in ultrasonography. Nephrogenic system fibrosis can be detected through a nuclear renal scan.

A patient is prescribed a urine culture and sensitivity test. What does the nurse tell the patient about obtaining a clean catch specimen?

Collect about 30 mL of midstream urine in the sterile container. The patient should collect about 30 mL of midstream urine in the sterile container by initiating voiding after cleaning the urethral meatus, stopping, and then voiding again. The remainder of the urine should be discarded. This removes secretions and bacteria because urine flushes the distal portion of the internal urethra. The first specimen voided in the morning is usually concentrated and should not be taken for a culture and sensitivity test. The urethra must be cleaned with the sponge and solution that is provided along with the sterile container to help remove secretions and bacteria and provide a clean urine specimen.

What does the nurse recognize as the cause for a high blood urea nitrogen (BUN) level in a patient?

Decreased kidney perfusion The kidneys filter urea nitrogen from the blood and excrete the waste in urine. BUN levels indicate the extent of kidney clearance of this nitrogen waste product. An increased BUN level indicates decreased kidney perfusion in the patient.

What risk does the nurse identify in a patient who is on a long-term, high-protein diet?

Formation of calculi or stones

Which medication causes diluted urine in patients with renal impairment?

Furosemide Diuretics such as, furosemide increase the flow of urine, thereby making the urine diluted in patients with renal impairment.

The nurse is reviewing the medical record for a patient with polycystic kidney disease who is scheduled for a computed tomography (CT) angiography with contrast: Which intervention is essential for the nurse to perform? Diagnostics: Prescriptions: BUN: 26 Glyburide Creatinine: 1.0 Metformin HbA1c: 6.9 Synthroid Glucose: 132

Hold the metformin 24 hours before and on the day of the procedure. Before studies with contrast media are performed, the nurse must withhold metformin, which may cause lactic acidosis. The focus of this admission is the polycystic kidneys; a TSH is not essential at this time. BUN and creatinine are normal. The glucose is only mildly elevated (if fasting), and the A1c is in an appropriate range.

The nurse is caring for a patient with an elevated blood urea nitrogen (BUN) of an unknown cause. If kidney disease has been ruled out, what additional conditions would the nurse suspect as a possible cause for an elevated BUN level? Select all that apply.

Infection Dehydration Decreased cardiac output Rapid cell destruction from infection may increase the BUN level. Additionally, dehydration and decreased cardiac output may increase the patient's BUN level.

The nurse is performing a physical assessment of the kidneys and bladder of a patient. How does the nurse perform this assessment?

Inspect for asymmetry in the costovertebral angle (CVA). The nurse should inspect the patient for asymmetry in the costovertebral angle (CVA), which is located between the lower portion of the twelfth rib and the vertebral column. The left kidney lies deep in the abdomen and often cannot be palpated. The nurse should ask the patient about areas of pain and tenderness and palpate these areas last to prevent discomfort during the examination. The assessment begins with inspection of the flanks and abdomen. Percussion of the abdomen starts from the lower abdomen to the umbilicus.

A nurse is admitting an older adult patient to the medical surgical floor and notes that the patient has a long list of current medications. What age-related physiological changes does the nurse recognize as contributing factors for the risk of delayed drug clearance in this patient? Select all that apply.

Kidney mass decreases with age Blood flow to the kidney decreases with age The glomerular filtration rate (GFR) decreases with age The combination of decreased kidney mass, decreased blood flow, and decreased glomerular filtration rate (GFR) in the older adult contributes to the risk of delayed drug clearance in this patient.

A nurse is caring for a patient who is scheduled for surgery later in the day. When reviewing the patient's medication history, what medications will alert the nurse to the possibility of the patient developing acute renal failure during the procedure? Select all that apply.

Laxatives Glucose regulators Beta adrenergic blockers

The nurse is studying the urinalysis report of a patient. What finding indicates the presence of a urinary tract infection (UTI) in the patient?

Leukoesterase Leukoesterase is an enzyme found in some white blood cells (WBCs), especially neutrophils. When these WBCs are lysed, the urine contains leukoesterase. The presence of leukoesterase indicates a UTI. Casts are formed from minerals; sticky materials in the urine clump around cells, bacteria, or proteins. Crystals in the urine come from mineral salts as a result of diet, drugs, or disease. Red blood cells in the urine can indicate injury to the urinary tract resulting from a catheterization or trauma.

What aspect of renal function is most important to assess?

Maintaining body fluid volume

A patient is scheduled for radiography of the kidneys, ureters, and bladder (KUB). What is the purpose of this examination?

Measure the size of both kidneys A KUB is a plain film of the abdomen used to measure the size of the kidneys. It is also used to screen for the presence of two kidneys and to detect gross obstruction. It does not help to stage a tumor.

The nurse is assessing a patient at the bedside using a bladder scanner. What is the purpose of this examination?

Measures post-void residual urine A bladder scanner is used to measure post-void residual urine and determine the need for intermittent catheterization.

The nurse is caring for a patient after a percutaneous biopsy of the kidney. What interventions does the nurse perform? Select all that apply.

Monitor the dressing site for 24 hours Monitor for flank pain Monitor for hematuria Maintain strict bedrest. The dressing site must be monitored for 24 hours after the biopsy because the major risk for this patient is bleeding from the biopsy site. Even if external bleeding is absent, the patient is likely to bleed internally. The nurse must ask the patient about any local pain, flank pain, or pain in the front of the abdomen because pain is indicative of the formation of hematoma around the kidney. Hematuria is the most common complication, occurring microscopically in most patients. The patient must have strict bedrest to prevent bleeding complications. The patient must be positioned supine with a back roll for support for 2 to 6 hours. The patient may have limited bathroom privileges if there is no evidence of bleeding.

The nurse visualizes blood clots in a patient's urinary catheter after a cystoscopy. What nursing intervention does the nurse perform first?

Notify the health care provider. Bleeding and/or blood clots are potential complications of cystocopy and may obstruct the catheter and decrease urine output. Monitor urine output and notify the health care provider of obvious blood clots or a decreased or absent urine output. Heparin will not be administered because of bleeding. The urinary catheter is allowing close monitoring of the urinary system and should not be removed at this time. The Foley catheter may be irrigated with sterile saline, if prescribed.

Which test is useful to estimate glomerular filtration rate (GFR)?

Nuclear renal scan A nuclear renal scan is used to estimate GFR. Radiography is used to detect any gross obstruction in the kidneys. Ultrasonography is used to identify the size of a tumor in the kidneys. Magnetic resonance imaging is useful to determine the stages of cancer.

Which diagnostic test may be used to evaluate renal perfusion and glomerular filtration rate (GFR) in a patient without exposing the patient to iodinated contrast dye?

Nuclear renal scan A nuclear renal scan is used to evaluate renal perfusion and estimate glomerular filtration rate. This method also provides functional information without exposing the patient to iodinated contrast dye.

A nurse is reviewing laboratory results of a patient with chronic kidney disease. The nurse notes that the patient's erythropoietin level is very low. What finding on the patient's assessment does the nurse contribute to the patient's laboratory result? Select all that apply.

Pale skin Reduced oxygen level Kidney disease often causes a decrease in erythropoietin, causing anemia. Anemia, or a decrease in red blood cells, may manifest as pale skin and reduced oxygen levels. Anemia would cause tachycardia (increased heart rate), not bradycardia (decreased heart rate). Jaundiced skin is caused by an increased amount of bilirubin in the blood, often caused by liver disease, not renal disease.

The nurse is assessing four patients with different conditions in a health care setting. Which patient may be harmed upon palpation of the urinary system?

Patient having a kidney aneurysm Palpation is the examination of the abdomen to determine any tenderness and pain. Palpation may harm a patient having a kidney aneurysm because it may result in rupture and renal failure. Aneurysm is an excessive localized swelling of the wall of an artery.

The charge nurse is making patient assignments for the day shift. Which patient is best to assign to an LPN/LVN?

Patient with polycystic kidney disease who is having a kidney ultrasound Kidney ultrasounds are noninvasive procedures without complications; the LPN/LVN can provide this care. A kidney artery angioplasty is an invasive procedure that requires postprocedure monitoring for complications, especially hemorrhage; a registered nurse is needed. Cystoscopy and cystourethroscopy are procedures that are associated with potentially serious complications such as bleeding and infection. These patients should be assigned to RN staff members. Kidney biopsy is associated with potentially serious complications such as bleeding, and this patient should be assigned to RN staff members.

A nurse is assessing the renal system of a patient who is complaining of left flank pain. What does the nurse recognize as the correct procedure for assessing and percussing the patient's flank pain?

Percuss the right flank before the left. If the patient complains of flank pain, the nurse should percuss the nontender flank first. In this case, the nurse should percuss the right flank before left. Even though the patient is complaining of pain, it is still important to assess both flank areas.

The nurse is performing an assessment on a patient with a suspected kidney injury. What is the best reason for auscultating before percussing or palpating when assessing the renal system?

Percussion and palpation prior to auscultating may increase bowel sounds, making it more difficult to hear vascular sounds.

Which percussion technique does the nurse use to assess a patient who reports flank pain?

Place one hand with the palm down flat over the flank area and use the other fisted hand to thump the hand on the flank. While the patient assumes a sitting, side-lying, or supine position, the nurse forms one of the hands into a clenched fist. The other hand is placed flat over the costovertebral (CVA) angle of the patient. Then, a firm thump is quickly delivered to the hand over the CVA area. Percussion is not appropriate for flank pain.

The RN is caring for a patient who has just had a kidney biopsy. Which action does the nurse perform first?

Position the patient supine. The patient is positioned supine for several hours after a kidney biopsy to decrease the risk for hemorrhage. BUN and creatinine would be obtained before the procedure is performed. Only local discomfort should be noted around the procedure site; severe pain would indicate hematoma. Although pink urine may develop, the nurse should position the patient to prevent bleeding first

A patient had a computed tomography (CT) with contrast dye 8 hours ago. Which nursing intervention is the priority for this patient?

Promoting fluid intake. The nurse should ensure adequate hydration by urging the patient to take oral fluid or by giving IV fluids. Hydration reduces the risk for kidney damage.

A patient with suspected renal impairment is scheduled to undergo radiological imaging to assess the perfusion to the kidneys. The patient tells the nurse that he is allergic to the contrast dye given in some radiological procedures. What procedure will the nurse recommend that the patient undergo?

Renal scan with radioisotope intravenous injection The renal scan with radioisotope intravenous injection is an imaging test that does not use an iodinated dye and so may be used in preference to a CT scan when the patient is allergic to iodine or has impaired kidney function that places him or her at risk for kidney injury from contrast dyes.

A patient who underwent a cystoscopy to remove an enlarged prostate gland has an indwelling catheter. What action does the nurse take?

Report any fever to the health care provider. Fever with or without chills is suggestive of infection and should be reported. The patient without an indwelling catheter will have urinary urgency following irritation from the procedure. Pink-tinged urine should be expected after a cystoscopy because of the presence of traces of blood, but gross bleeding and blood clots are not generally expected. The patient should be urged to consume oral fluids to increase urine output to prevent clotting.

Which statement is true regarding an ultrasound scanner?

Round dome of the scan head area is moistened with 5 mL of conducting gel. Ultrasound scanner is a non-invasive method of estimating bladder volume. Moistening the round dome of the scan head area with 5 mL of conducting gel will improve the ultrasound's conduction. Using gel on the scanner head is beneficial in patients who are obese and who have lots of body hair in the area to be scanned. Ultrasound scanner does not cause any discomfort to the patient.

An athlete is admitted to the hospital with kidney dysfunction. What might be a reason for causing kidney dysfunction in this patient?

Taking dietary supplementation with synthetic creatine Dietary supplementation with synthetic creatine results in an increase of muscle mass. But, it causes compromised kidney function. Long-term use of analgesics leads to kidney dysfunction. High impact exercises may not affect kidney function. Long-term use of nonsteroidal anti-inflammatory drugs, especially acetaminophen, leads to reduced kidney function.

What changes related to aging does the nurse expect in the kidneys of an older patient?

The kidney loses cortical tissue. Structural and functional changes occur in the kidneys as a result of aging. The kidneys lose cortical tissue following reduced blood flow to the kidneys. The medulla is not affected by aging and the juxtamedullary nephron functions are preserved. The glomerular and tubular linings thicken and their surface areas decrease with age. The tubules decrease in length. These changes reduce the ability of the older adult to filter and excrete waste products.

Which finding in a patient's kidney, ureter, and bladder (KUB) x-ray indicates an abnormality?

The left kidney is much larger than the right kidney The left kidney is usually slightly narrower and longer than the right kidney. The presence of a larger-than-usual left kidney indicates the possibility of obstruction or polycystic disease. The kidneys are normally located on either side of the spine.

An older adult patient tells the nurse, "I urinate so many times in the night that I don't sleep well. Also, during the day I feel like I have to urinate all the time even if I can't urinate when I try." What age-related pathophysiological changes to the patient's renal system will the nurse recognize as the likely cause of the patient's symptoms?

Tubular changes with aging decrease the ability to concentrate urine. Tubular changes with aging decrease the ability to concentrate urine, resulting in urgency (a sense of nearly uncontrollable need to urinate) and nocturnal polyuria (increased urination at night). Blood flow to the kidney decreases with age, as does the GFR; however, these do not directly cause urgency and polyuria.

Which assessment finding alarms the nurse immediately after a patient returns from the operating room for cystoscopy performed under conscious sedation?

Which assessment finding alarms the nurse immediately after a patient returns from the operating room for cystoscopy performed under conscious sedation? Fever, chills, or an elevated white blood cell (WBC) count after cystoscopy suggest infection after an invasive procedure; the provider must be notified immediately. Pink-tinged urine is expected after a cystoscopy; gross hematuria would require notification of the surgeon. Frequency may be noted as a result of irritation of the bladder. If sedation or anesthesia were used, lethargy would be an expected effect.