Ch. 27 - The Child with Genitourinary Dysfunction

1. The nurse is caring for an infant with a suspected urinary tract infection. Which clinical manifestations should be expected? (Select all that apply.) a. Vomiting b. Jaundice c. Failure to gain weight d. Swelling of the face e. Back pain f. Persistent diaper rash

ANS: A, C, F Vomiting, failure to gain weight, and persistent diaper rash are clinical manifestations observed in an infant with a UTI.

2. A school-age child is admitted to the hospital with acute glomerulonephritis and oliguria. Which dietary menu items should be allowed for this child? (Select all that apply.) a. Apples b. Bananas c. Cheese d. Carrot sticks e. Strawberries

ANS: A, D, E Moderate sodium restriction and even fluid restriction may be instituted for children with acute glomerulonephritis. Foods with substantial amounts of potassium are generally restricted during the period of oliguria. Apples, carrot sticks, and strawberries would be items low in sodium and allowed. Bananas are high in potassium and cheese is high in sodium. Those items would be restricted.

1. The nurse is conducting a staff in-service on renal ultrasounds. Which statement describes this diagnostic test? a. Computed tomography uses external radiation to visualize the renal system. b. Visualization of the renal system is accomplished without exposure to radiation or radioactive isotopes. c. Contrast medium and x-rays allow for visualization of the renal system. d. External radiation for x-ray films is used to visualize the renal system, before, during, and after voiding.

ANS: A A renal ultrasound transmits ultrasonic waves through the renal parenchyma allowing for visualization of the renal system without exposure to external beam radiation or radioactive isotopes. Computed tomography uses external radiation and sometimes contrast media to visualize the renal system. An intravenous pyelogram uses contrast medium and external radiation for x-ray films. The voiding cystourethrogram visualizes the renal system with injection of a contrast media into the bladder through the urethral opening and use of x-ray before, during, and after voiding.

9. Which is instituted for the therapeutic management of minimal change nephrotic syndrome? a. Corticosteroids b. Antihypertensive agents c. Long-term diuretics d. Increased fluids to promote diuresis

ANS: A Corticosteroids are the first line of therapy for minimal change nephrotic syndrome. Response is usually seen within 7 to 21 days. Antihypertensive agents and long-term diuretic therapy are usually not necessary. A diet that has fluid and salt restrictions may be indicated.

5. Which should the nurse recommend to prevent urinary tract infections in young girls? a. Wear cotton underpants. b. Limit bathing as much as possible. c. Increase fluids; decrease salt intake. d. Cleanse perineum with water after voiding.

ANS: A Cotton underpants are preferable to nylon underpants. No evidence exists that limiting bathing, increasing fluids/decreasing salt intake, or cleansing the perineum with water after voiding decrease urinary tract infections in young girls.

12. A hospitalized child with minimal change nephrotic syndrome is receiving high doses of prednisone. Which is an appropriate nursing goal related to this? a. Prevent infection. b. Stimulate appetite. c. Detect evidence of edema. d. Ensure compliance with prophylactic antibiotic therapy.

ANS: A High-dose steroid therapy has an immunosuppressant effect. These children are particularly vulnerable to upper respiratory tract infections. A priority nursing goal is to minimize the risk of infection by protecting the child from contact with infectious individuals. Appetite is increased with prednisone therapy. The amount of edema should be monitored as part of the disease process, not necessarily related to the administration of prednisone. Antibiotics would not be used as prophylaxis.

11. The nurse closely monitors the temperature of a child with minimal change nephrotic syndrome. The purpose of this assessment is to detect an early sign of which possible complication? a. Infection b. Hypertension c. Encephalopathy d. Edema

ANS: A Infection is a constant source of danger to edematous children and those receiving corticosteroid therapy. An increased temperature could be an indication of an infection. Temperature is not an indication of hypertension or edema. Encephalopathy is not a complication usually associated with minimal change nephrotic syndrome. The child will most likely have neurologic signs and symptoms.

3. The nurse is conducting an assessment on a school-age child with urosepsis. Which assessment finding should the nurse expect? a. Fever with a positive blood culture b. Proteinuria and edema c. Oliguria and hypertension d. Anemia and thrombocytopenia

ANS: A Symptoms of urosepsis include a febrile UTI coexisting with systemic signs of bacterial illness; blood culture reveals presence of urinary pathogen. Proteinuria and edema are symptoms of minimal change nephrotic syndrome (MCNS). Oliguria and hypertension are symptoms of acute glomerulonephritis (AGN). Anemia and thrombocytopenia are symptoms of hemolytic uremic syndrome (HUS).

20. The nurse is admitting a child with a Wilms tumor. Which is the initial assessment finding associated with this tumor? a. Abdominal swelling b. Weight gain c. Hypotension d. Increased urinary output

ANS: A The initial assessment finding with a Wilms (kidney) tumor is abdominal swelling. Weight loss, not weight gain, may be a finding. Hypertension occasionally occurs with a Wilms tumor. Urinary output is not increased, but hematuria may be noted.

22. The nurse is conducting an admission assessment on a school-age child with acute renal failure. Which are the primary clinical manifestations the nurse expects to find with this condition? a. Oliguria and hypertension b. Hematuria and pallor c. Proteinuria and muscle cramps d. Bacteriuria and facial edema

ANS: A The principal feature of acute renal failure is oliguria; hypertension is a nonspecific clinical manifestation. Hematuria and pallor, proteinuria and muscle cramps, and bacteriuria and facial edema are not principal features of acute renal failure.

24. When a child has chronic renal failure, the progressive deterioration produces a variety of clinical and biochemical disturbances that eventually are manifested in the clinical syndrome known as: a. uremia. b. oliguria. c. proteinuria. d. pyelonephritis.

ANS: A Uremia is the retention of nitrogenous products, producing toxic symptoms. Oliguria is diminished urinary output. Proteinuria is the presence of protein, usually albumin, in the urine. Pyelonephritis is an inflammation of the kidney and renal pelvis.

14. Which best describes acute glomerulonephritis? a. Occurs after a urinary tract infection b. Occurs after a streptococcal infection c. Associated with renal vascular disorders d. Associated with structural anomalies of genitourinary tract

ANS: B Acute glomerulonephritis is an immune-complex disease that occurs after a streptococcal infection with certain strains of the group A â-hemolytic streptococcus. Acute glomerulonephritis usually follows streptococcal pharyngitis and is not associated with renal vascular disorders or genitourinary tract structural anomalies.

36. A school-age child with chronic renal failure is admitted to the hospital with a serum potassium level of 5.2 mEq/L. Which prescribed medication should the nurse plan to administer? a. Spironolactone (Aldactone) b. Sodium polystyrene sulfonate (Kayexalate) c. Lactulose (Cephulac) d. Calcium carbonate (Calcitab)

ANS: B Normal serum potassium levels in a school-age child are 3.5 to 5 mEq/L. Sodium polystyrene sulfonate is administered to reduce serum potassium levels. Spironolactone is a potassium sparing diuretic and should not be used if the serum potassium is elevated. Lactulose is administered to reduce ammonia levels in patients with liver disease. Calcium carbonate may be prescribed as a calcium supplement, but it will not reduce serum potassium levels.

28. Calcium carbonate is given with meals to a child with chronic renal disease. The purpose of this is to: a. prevent vomiting. b. bind phosphorus. c. stimulate appetite. d. increase absorption of fat-soluble vitamins.

ANS: B Oral calcium carbonate preparations combine with phosphorus to decrease gastrointestinal absorption and the serum levels of phosphate. Serum calcium levels are increased by the calcium carbonate, and vitamin D administration is necessary to increase calcium absorption. Calcium carbonate does not prevent vomiting, stimulate appetite, or increase the absorption of fat-soluble vitamins.

7. The nurse is conducting a staff in-service on newborn defects of the genitourinary system. Which describes the narrowing of the preputial opening of the foreskin? a. Chordee b. Phimosis c. Epispadias d. Hypospadias

ANS: B Phimosis is the narrowing or stenosis of the preputial opening of the foreskin. Chordee is the ventral curvature of the penis. Epispadias is the meatal opening on the dorsal surface of the penis. Hypospadias is a congenital condition in which the urethral opening is located anywhere along the ventral surface of the penis.

32. Which statement is descriptive of renal transplantation in children? a. It is an acceptable means of treatment after age 10 years. b. It is the preferred means of renal replacement therapy in children. c. Children can receive kidneys only from other children. d. The decision for transplantation is difficult because a relatively normal lifestyle is not possible.

ANS: B Renal transplant offers the opportunity for a relatively normal life and is the preferred means of renal replacement therapy in end-stage renal disease. Renal transplantation can be done in children as young as age 6 months. Both children and adults can serve as donors for renal transplant purposes. Renal transplantation affords the child a more normal lifestyle than dependence on dialysis.

13. Which is included in the diet of a child with minimal change nephrotic syndrome? a. High protein b. Salt restriction c. Low fat d. High carbohydrate

ANS: B Salt is usually restricted (but not eliminated) during the edema phase. The child has little appetite during the acute phase. Favorite foods are provided (with the exception of high-salt ones) in an attempt to provide nutritionally complete meals.

34. The nurse is conducting teaching for an adolescent being discharged to home after a renal transplant. The adolescent needs further teaching if which statement is made? a. "I will report any fever to my primary health care provider." b. "I am glad I only have to take the immunosuppressant medication for two weeks." c. "I will observe my incision for any redness or swelling." d. "I won't miss doing kidney dialysis every week."

ANS: B The immunosuppressant medications are taken indefinitely after a renal transplant, so they should not be discontinued after two weeks. Reporting a fever and observing an incision for redness and swelling are accurate statements. The adolescent is correct in indicating dialysis will not need to be done after the transplant.

8. Which is an objective of care for a 10-year-old child with minimal change nephrotic syndrome? a. Reduce blood pressure. b. Reduce excretion of urinary protein. c. Increase excretion of urinary protein. d. Increase ability of tissues to retain fluid.

ANS: B The objectives of therapy for the child with minimal change nephrotic syndrome include reduction of the excretion of urinary protein, reduction of fluid retention, prevention of infection, and minimization of complications associated with therapy. Blood pressure is usually not elevated in minimal change nephrotic syndrome. Excretion of urinary protein and fluid retention are part of the disease process and must be reversed.

4. The nurse is teaching parents about prevention of urinary tract infections in children. Which factor predisposes the urinary tract to infection? a. Increased fluid intake b. Short urethra in young girls c. Prostatic secretions in males d. Frequent emptying of the bladder

ANS: B The short urethra in females provides a ready pathway for invasion of organisms. Increased fluid intake and frequent emptying of the bladder offer protective measures against urinary tract infections. Prostatic secretions have antibacterial properties that inhibit bacteria.

27. One of the clinical manifestations of chronic renal failure is uremic frost. Which best describes this term? a. Deposits of urea crystals in urine b. Deposits of urea crystals on skin c. Overexcretion of blood urea nitrogen d. Inability of body to tolerate cold temperatures

ANS: B Uremic frost is the deposition of urea crystals on the skin. The urea crystals are present on the skin, not in the urine. The kidneys are unable to excrete blood urea nitrogen, leading to elevated levels. There is no relation between cold temperatures and uremic frost.

15. A child is admitted with acute glomerulonephritis. The nurse should expect the urinalysis during this acute phase to show: a. bacteriuria, hematuria. b. hematuria, proteinuria. c. bacteriuria, increased specific gravity. d. proteinuria, decreased specific gravity.

ANS: B Urinalysis during the acute phase characteristically shows hematuria and proteinuria. Bacteriuria and changes in specific gravity are not usually present during the acute phase.

4. A 6-year-old child is scheduled for an IV urography (IVP) in the morning. Which preparatory interventions should the nurse plan to implement? (Select all that apply.) a. Clear liquids in the morning before the procedure b. Cathartic in the evening before the procedure c. Soapsuds enema the morning of the procedure d. Insertion of a Foley catheter before the procedure e. Teaching with regard to insertion of an intravenous catheter before the procedure

ANS: B, C, E The IV urography is a test done to provide information about the integrity of the kidneys, ureters, and bladder. It requires an IV injection of a contrast medium with X-ray films made 5, 10, and 15 minutes after injection. Delayed films (30, 60 minutes, and so on) are also obtained. The preparation for children ages 2 to 14 years includes cathartic on the evening before examination, nothing orally after midnight, and an enema (soapsuds) on the morning of examination. Teaching about the insertion of an intravenous catheter should be part of the preoperative preparation. Insertion of a Foley catheter is not part of the preparation for an IVP.

3. A school-age child has been admitted to the hospital with an exacerbation of nephrotic syndrome. Which clinical manifestations should the nurse expect to assess? (Select all that apply.) a. Weight loss b. Facial edema c. Cloudy smoky brown-colored urine d. Fatigue e. Frothy-appearing urine

ANS: B, D, E A child with nephrotic syndrome will present with facial edema, fatigue, and frothy-appearing urine (proteinuria). Weight gain, not loss, is expected because of the fluid retention. Cloudy smoky brown-colored urine is seen with acute glomerulonephritis but not with nephrotic syndrome because there is no gross hematuria associated with nephrotic syndrome.

26. Which clinical manifestation would be seen in a child with chronic renal failure? a. Hypotension b. Massive hematuria c. Hypokalemia d. Unpleasant "uremic" breath odor

ANS: D Children with chronic renal failure have a characteristic breath odor resulting from the retention of waste products. Hypertension may be a complication of chronic renal failure. With chronic renal failure, little or no urinary output occurs. Hyperkalemia is a concern in chronic renal failure.

35. The nurse is teaching parents of a child with chronic renal failure (CRF) about the use of recombinant human erythropoietin (rHuEPO) subcutaneous injections. Which statement indicates the parents have understood the teaching? a. "These injections will help with the hypertension." b. "We're glad the injections only need to be given once a month." c. "The red blood cell count should begin to improve with these injections." d. "Urine output should begin to improve with these injections."

ANS: C Anemia in children with CRF is related to decreased production of erythropoietin. Recombinant human erythropoietin (rHuEPO) is being offered to these children as thrice-weekly or weekly subcutaneous injections and is replacing the need for frequent blood transfusions. The parents understand the teaching if they say that the red blood cell count will begin to improve with these injections.

25. Which is a major complication in a child with chronic renal failure? a. Hypokalemia b. Metabolic alkalosis c. Water and sodium retention d. Excessive excretion of blood urea nitrogen

ANS: C Chronic renal failure leads to water and sodium retention, which contributes to edema and vascular congestion. Hyperkalemia, metabolic acidosis, and retention of blood urea nitrogen are complications of chronic renal failure.

29. Which should the nurse recommend for the diet of a child with chronic renal failure? a. High in protein b. Low in vitamin D c. Low in phosphorus d. Supplemented with vitamins A, E, and K

ANS: C Dietary phosphorus is controlled by the reduction of protein and milk intake to prevent or control the calcium-phosphorus imbalance. Protein should be limited in chronic renal failure to decrease intake of phosphorus. Vitamin D therapy is administered in chronic renal failure to increase calcium absorption. Supplementation of vitamins A, E, and K is not part of dietary management in chronic renal disease.

18. The nurse is teaching the parent about the diet of a child experiencing severe edema associated with acute glomerulonephritis. Which information should the nurse include in the teaching? a. "You will need to decrease the number of calories in your child's diet." b. "Your child's diet will need an increased amount of protein." c. "You will need to avoid adding salt to your child's food." d. "Your child's diet will consist of low-fat, low-carbohydrate foods."

ANS: C For most children, a regular diet is allowed, but it should contain no added salt. The child should be offered a regular diet with favorite foods. Severe sodium restrictions are not indicated.

19. Which is the most appropriate nursing diagnosis for the child with acute glomerulonephritis? a. Risk for Injury related to malignant process and treatment b. Fluid Volume Deficit related to excessive losses c. Fluid Volume Excess related to decreased plasma filtration d. Fluid Volume Excess related to fluid accumulation in tissues and third spaces

ANS: C Glomerulonephritis has a decreased filtration of plasma, which results in an excessive accumulation of water and sodium that expands plasma and interstitial fluid volumes, leading to circulatory congestion and edema. No malignant process is involved in acute glomerulonephritis. A fluid volume excess is found. The fluid accumulation is secondary to the decreased plasma filtration.

2. The nurse is admitting a school-age child in acute renal failure with reduced glomerular filtration rate. Which urine test is the most useful clinical indication of glomerular filtration rate? a. pH b. Osmolality c. Creatinine d. Protein level

ANS: C The most useful clinical indication of glomerular filtration is the clearance of creatinine. It is a substance that is freely filtered by the glomerulus and secreted by the renal tubule cells. The pH and osmolality are not estimates of glomerular filtration. Although protein in the urine demonstrates abnormal glomerular permeability, it is not a measure of filtration rate.

17. The nurse notes that a child has lost 8 pounds after 4 days of hospitalization for acute glomerulonephritis. This is most likely the result of: a. poor appetite. b. increased potassium intake. c. reduction of edema. d. restriction to bed rest.

ANS: C This amount of weight loss in this period is a result of the improvement of renal function and mobilization of edema fluid. Poor appetite and bed rest would not result in a weight loss of 8 pounds in 4 days. Foods with substantial amounts of potassium are avoided until renal function is normalized.

16. A mother asks the nurse what would be the first indication that acute glomerulonephritis is improving. The nurse's best response should be that the: a. blood pressure will stabilize. b. the child will have more energy. c. urine will be free of protein. d. urinary output will increase.

ANS: D An increase in urinary output may signal resolution of the acute glomerulonephritis. If blood pressure is elevated, stabilization usually occurs with the improvement in renal function. The child having more energy and the urine being free of protein are related to the improvement in urinary output.

23. The nurse is caring for a child with acute renal failure. Which clinical manifestation should the nurse recognize as a sign of hyperkalemia? a. Dyspnea b. Seizure c. Oliguria d. Cardiac arrhythmia

ANS: D Hyperkalemia is the most common threat to the life of the child. Signs of hyperkalemia include electrocardiograph anomalies such as prolonged QRS complex, depressed ST segments, peaked T waves, bradycardia, or heart block. Dyspnea, seizure, and oliguria are not manifestations of hyperkalemia.

6. The nurse is admitting a newborn with hypospadias to the nursery. The nurse expects which finding in this newborn? a. Absence of a urethral opening is noted. b. Penis appears shorter than usual for age. c. The urethral opening is along the dorsal surface of the penis. d. The urethral opening is along the ventral surface of the penis.

ANS: D Hypospadias is a congenital condition in which the urethral opening is located anywhere along the ventral surface of the penis. The urethral opening is present, but not at the glans. Hypospadias refers to the urethral opening, not to the size of the penis. Urethral opening along ventral surface of penis is known as epispadias.

30. The nurse is caring for an adolescent who has just started dialysis. The child seems always angry, hostile, or depressed. The nurse should recognize that this is most likely related to: a. neurologic manifestations that occur with dialysis. b. physiologic manifestations of renal disease. c. adolescents having few coping mechanisms. d. adolescents often resenting the control and enforced dependence imposed by dialysis.

ANS: D Older children and adolescents need control. The necessity of dialysis forces the adolescent into a dependent relationship, which results in these behaviors. These are a function of the child's age, not neurologic or physiologic manifestations of the dialysis. Feelings of anger, hostility, and depression are functions of the child's age, not neurologic or physiologic manifestations of the dialysis. Adolescents do have coping mechanisms, but they need to have some control over their disease management.

31. Which is an advantage of peritoneal dialysis? a. Treatments are done in hospitals. b. Protein loss is less extensive. c. Dietary limitations are not necessary. d. Parents and older children can perform treatments.

ANS: D Peritoneal dialysis is the preferred form of dialysis for parents, infants, and children who wish to remain independent. Parents and older children can perform the treatments themselves. Treatments can be done at home. Protein loss is not significantly different. The dietary limitations are necessary, but they are not as stringent as those for hemodialysis.

10. Which is a common side effect of short-term corticosteroid therapy? a. Fever b. Hypertension c. Weight loss d. Increased appetite

ANS: D Side effects of short-term corticosteroid therapy include an increased appetite. Fever is not a side effect of therapy. It may be an indication of infection. Hypertension is not usually associated with initial corticosteroid therapy. Weight gain, not weight loss, is associated with corticosteroid therapy.

21. Which is the most common cause of acute renal failure in children? a. Pyelonephritis b. Tubular destruction c. Urinary tract obstruction d. Severe dehydration

ANS: D The most common cause of acute renal failure in children is dehydration or other causes of poor perfusion that may respond to restoration of fluid volume. Pyelonephritis and tubular destruction are not common causes of acute renal failure. Obstructive uropathy may cause acute renal failure, but it is not the most common cause.

33. A preschool child is being admitted to the hospital with dehydration and a urinary tract infection (UTI). Which urinalysis result should the nurse expect with these conditions? a. WBC <1; specific gravity 1.008 b. WBC <2; specific gravity 1.025 c. WBC >2; specific gravity 1.016 d. WBC >2; specific gravity 1.030

ANS: D WBC count in a routine urinalysis should be <1 or 2. Over that amount indicates a urinary tract inflammatory process. The urinalysis specific gravity for children with normal fluid intake is 1.016 to 1.022. When the specific gravity is high, dehydration is indicated. A low specific gravity is seen with excessive fluid intake, distal tubular dysfunction, or insufficient antidiuretic hormone secretion.