CHAPTER 33- DISORDERS OF RENAL FUNCTION
Which statement about the use of angiotensin-converting enzyme (ACE) inhibitors and autosomal recessive polycystic kidney disease (ARPKD) is accurate? The use of ACE inhibitors will increase the vasopressin levels. ACE inhibitors may interrupt the renin-angiotensin-aldosterone system to reduce renal vasoconstriction. The ACE inhibitors have been shown to shrink the size of the cysts inside the kidneys. ACE inhibitors should be used strictly in those clients who also have an underlying cardiac history.
ACE inhibitors may interrupt the renin-angiotensin-aldosterone system to reduce renal vasoconstriction. EXPLANATION: In addition to increasing water intake to decrease vasopressin levels, the angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) may be used to interrupt the renin-angiotensin-aldosterone system as a means of reducing intraglomerular pressure and renal vasoconstriction. Although not approved by the Food and Drug Administration (FDA), there has been recent interest in the use of vasopressin receptor antagonists (vaptans) to decrease cyst development.
A 34-year-old woman presents with an abrupt onset of shaking chills, moderate to high fever, and a constant ache in her lower back. She is also experiencing dysuria, urinary frequency, and a feeling of urgency. Her partner states that she has been very tired the last few days and that she looked like she may have the flu. What is the most likely diagnosis? Renal cell carcinoma Acute renal failure Renal calculi Acute pyelonephritis
Acute pyelonephritis EXPLANATION: Acute pyelonephritis tends to present with an abrupt onset of shaking chills, moderate to high fever, and a constant ache in the loin area of the back that is unilateral or bilateral. Lower urinary tract symptoms, including dysuria, frequency, and urgency also are common. There may be significant malaise, and the person usually looks and feels ill. Nausea and vomiting may occur along with abdominal pain. Cancer, kidney stones, and acute renal failure have different presentations.
The nurse suspects that a newborn infant who presents with bilateral flank masses, impaired lung development, and oliguria may be suffering from which disorder? Autosomal recessive polycystic kidney disease (ARPKD) Simple renal cysts Autosomal dominant polycystic kidney disease (ADPKD) Horseshoe kidney abnormality
Autosomal recessive polycystic kidney disease (ARPKD) EXPLANATION: The typical infant with ARPKD presents with bilateral flank masses accompanied by severe renal failure, signs of impaired lung development, and variable degrees of liver fibrosis and portal hypertension.
The most important information for a nurse to give a client who has been diagnosed and treated for a calcium oxalate stone would include which facts related to their diet? Avoid spinach and peanuts Avoid milk and dairy products Increase intake of citrus juices Take a thiazide diuretic
Avoid spinach and peanuts EXPLANATION: Persons who form calcium oxalate stones may need to decrease their intake of foods that are high in oxalate (e.g., spinach, Swiss chard, cocoa, chocolate, pecans, and peanuts). Taking a thiazide diuretic helps to prevent calcium stone redevelopment but is not a dietary change.
Acute pyelonephritis is a result of: Bacterial infection Renal failure Viral infection Chronic reflux
Bacterial infection EXPLANATION: Acute pyelonephritis represents a bacterial infection of the upper urinary tract, specifically the kidney parenchyma and renal pelvis. Gram-negative bacteria, including Escherichia coli and Proteus, Klebsiella, Enterobacter, and Pseudomonas species, are the common causative agents. Staphylococcus species and Streptococcus faecalis may also cause pyelonephritis, but they are uncommon.
A client who has had an intestinal bypass has developed a kidney stone. Which type of kidney stone does the nurse recognize that this client will most likely be treated for? Cystine Uric acid Magnesium ammonium Calcium
Calcium EXPLANATION: Most kidney stones are calcium stones—calcium oxalate, calcium phosphate, or a combination of the two materials. Clients who have had intestinal bypass surgery are at a higher risk for developing calcium kidney stones.
Hospitalized neonates are at greatest risk of developing septicemia related to which procedure? Catheter-associated bacteriuria Collection of urine for analysis Arterial blood gas measurement Suctioning of tracheostomy
Catheter-associated bacteriuria EXPLANATION: Catheter-associated bacteriuria remains the most frequent cause of Gram-negative septicemia in hospitalized neonates. The other procedures can cause bacteremia but are not the primary cause for this.
The family asks the nurse what the usual treatment of focal segmental glomerulosclerosis entails. What is the nurse's best response? Pain medications Antibiotics Antiviral medications Corticosteroids
Corticosteroids EXPLANATION: The disorder usually is treated with corticosteroids. Although kidney transplantation is the preferred treatment for end-stage kidney disease, focal segmental glomerulonephritis occurs in half of these people. Pain medications may help relieve symptoms but will not treat the disease. Antivirals and antibiotics are not effective in FSGS.
What is the most common cause of a lower urinary tract infection? Staphylococcus saprophyticus Pseudomonas aeruginosa Escherichia coli Staphylococcus aureus
Escherichia coli EXPLANATION: Most uncomplicated lower UTIs are caused by Escherichia coli. The other organisms can cause UTIs, but are not the most common cause of infection.
Which procedure is a nonsurgical method of treatment for renal calculi (kidney stones)? Extracorporeal shock wave lithotripsy (ESWL) Percutaneous ureterolithotomy Percutaneous nephrolithotomy Retrograde ureteroscopy
Extracorporeal shock wave lithotripsy (ESWL) EXPLANATION: ESWL is a nonsurgical treatment that uses sound waves, laser, or dry shock wave energy to break apart the stones. All of the other procedures are surgical in nature.
Which client clinical manifestation most clearly suggests a need for diagnostic testing to rule out renal cell carcinoma? Urinary urgency Hematuria Oliguria Cloudy urine
Hematuria EXPLANATION: Presenting features of renal cancer include hematuria, flank pain, and presence of a palpable flank mass. Gross or microscopic hematuria, which occurs in more than 50% of cases, is an important clinical clue. Urgency, oliguria, and cloudy urine are not as closely associated with renal carcinoma.
Which stresses can cause injury to the kidney glomerulus? Select all that apply. Immunologic Nonimmunologic Heredity Diabetes Arthritis Asthma
Immunologic Nonimmunologic Heredity Diabetes EXPLANATION: Most cases of primary and many cases of secondary glomerular disease probably have an immune origin. Although many glomerular diseases are driven by immunologic events, a variety of metabolic (e.g., diabetes), hemodynamic (e.g., hypertension), and toxic (e.g., drugs, chemicals) stresses can induce glomerular injury, either alone or in concert with immunologic mechanisms. Arthritis and asthma would not affect the glomerulus.
The nurse is assessing a client who has a unilateral obstruction of the urinary tract. Which clinical finding by the nurse correlates to this diagnosis? Increase in blood pressure Excretion of dilute urine Increased urine output Inability to control urination
Increase in blood pressure EXPLANATION: Hypertension is an occasional complication of urinary tract obstruction. It is more common in cases of unilateral obstruction in which renin secretion is enhanced, probably secondary to impaired renal blood flow. In these circumstances, removal of the obstruction often leads to a reduction in blood pressure. The urine output would be decreased and not diluted.
A nurse advises a client with recurring UTIs to drink large amounts of water. What normal protective action is the nurse telling the client to utilize? Decrease acidity of urine Increase washout of urine Thin mucus to prevent bacterial adherence Increase immune availability
Increase washout of urine EXPLANATION: The normal flow of urine functions to wash bacteria from the urinary tract. If a client is not drinking enough, urine can become stagnant and promote infection. Increased consumption of water will increase the washout. Water has no effect on acidity, consistency of mucus, or immune function.
Unilateral obstruction of the urinary tract may result in renin secretion, thereby leading to which manifestation? Increased blood pressure Increased urinary output Decreased heart rate Decreased sodium retention
Increased blood pressure EXPLANATION: In cases of unilateral obstruction of the kidney, renin secretion is enhanced, probably secondary to impaired renal blood flow. This would result in increased sodium retention, and increased blood pressure. Urine output would be decreased, and heart rate would not necessarily be affected.
Wilms tumor is a tumor of childhood. It is usually an encapsulated mass occurring in any part of the kidney. What are the common presenting signs of a Wilms tumor? Hypotension and a large abdominal mass Vomiting and oliguria Abdominal pain and diarrhea Large asymptomatic abdominal mass and hypertension
Large asymptomatic abdominal mass and hypertension EXPLANATION: The common presenting signs of a Wilms tumor are a large asymptomatic abdominal mass and hypertension. The tumor is often discovered inadvertently, and it is not uncommon for the mother to discover it while bathing the child. Some children may present with abdominal pain, vomiting, or both. Hypotension, oliguria, and diarrhea are not common presenting signs of a Wilms tumor.
A nurse is caring for a client who is diagnosed with acute poststreptococcal glomerulonephritis. Which renal disorder is most commonly associated with acute post-streptococcal glomerulonephritis? Occult hematuria Nephritic syndrome Nephrotic syndrome Renal colic
Nephritic Syndrome EXPLANATION: The acute nephritic syndrome is the clinical correlate of acute glomerular inflammation. The nephritic syndromes produce a proliferative inflammatory response, whereas the nephrotic syndrome produces increased permeability of the glomerulus. The acute nephritic syndrome may occur in such a systemic disease as systemic lupus erythematosus. Typically, however, it is associated with acute proliferative glomerulonephritis such as postinfectious glomerulonephritis. Acute postinfectious glomerulonephritis usually occurs after infection with certain strains of group A beta-hemolytic streptococci and is caused by deposition of immune complexes of antibody and bacterial antigens.
The nurse is presenting an educational program about renal carcinoma. The nurse determines that the participants understand early signs of the disease when they identify which as an early sign or symptom? Hematuria Flank pain Palpable flank mass None of the above
None of the above EXPLANATION: Kidney cancer is largely a silent disorder during its early stages, and symptoms usually denote advanced disease. Presenting features of kidney cancer include hematuria, flank pain, and a palpable flank mass, but again these are usually signs and symptoms of advanced disease.
Which assessment finding would lead the nurse to suspect the client has developed nephrotic syndrome? Hematuria and anemia Proteinuria and generalized edema Renal colic and increased serum sodium Increased creatinine with normal blood urea nitrogen
Proteinuria & generalized edema EXPLANATION: The nephrotic syndrome is characterized by massive proteinuria and lipiduria, along with an associated hypoalbuminemia, generalized edema, and hyperlipidemia. Hematuria and anemia may be associated with a cancer. Renal colic is characteristic of kidney stones. Increased creatinine may be associated with systemic lupus erythematosus.
What is a common cause of acute pyelonephritis, an infection of the renal parenchyma and renal pelvis? Group A β-hemolytic streptococci Pseudomonas species Haemophilus influenzae Candida albicans
Pseudomonas species EXPLANATION: The most common causative agents of acute pyelonephritis are Gram-negative bacteria, including E. coli and Proteus, Klebsiella, Enterobacter, and Pseudomonas. The other answers are not considered common causative agents of acute pyelonephritis.
What is the most common cancer of the kidney? Wilms tumor Transitional cell carcinoma Renal cell carcinoma Lymphoma
Renal cell carcinoma EXPLANATION: Renal cell carcinoma accounts for 80% to 90% of all kidney tumors.
The nurse is performing a history and physical on a client with diabetic nephropathy. Findings include BP 124/80; smokes two packs of cigarettes/day; diet high in saturated fats and sodium. Which intervention can help prevent the progression of the diabetic nephropathy? Smoking cessation program Walking program Increase dietary sodium intake DASH diet with limited caloric intake
Smoking cessation program EXPLANATION: Hypertension and cigarette smoking have been implicated in the progression of diabetic nephropathy. The control of blood pressure (the client has a normal BP at this time) and smoking cessation will help prevent the progression of diabetic nephropathy. The other dietary interventions may be recommended; however, there is not a correlation that they will prevent the development of diabetic nephropathy.
A nurse observes that a client's urine is cola colored and considers which factor as a possible reason? The client has ingested a dark-colored drink. The client's urine contains material from the degradation of red blood cells. The client has an elevation of urine potassium. The client's urine has a decrease in the specific gravity.
The client's urine contains material from the degradation of red blood cells EXPLANATION: When red blood cells degrade in the urine, urine may appear cola colored.
An obese client with a history of gout and a sedentary lifestyle has been advised by the primary health care provider to avoid organ meats, certain fish, and other foods that are high in purines. This treatment would be advised for which type of kidney stones? Calcium stones Magnesium ammonium phosphate stones Uric acid stones Cystine stones
Uric Acid Stones EXPLANATION: Uric acid stones develop in conditions of gout and when high concentrations of uric acid develop in the urine. Unlike radiopaque calcium stones, uric acid stones are not visible on x-ray films. These stones develop in clients who eat a high-purine diet like Atkins.
The nurse caring for an older adult notes a marked decrease in mental acuity over a 24-hour period. What assessment indicates the most likely cause of this change? Hearing aid batteries are run down No bowel movement in 48 hours Exacerbation of osteoarthritis Urine cloudy with strong odor
Urine cloudy with strong odor EXPLANATION: Older adults are prone to infections without obvious symptoms of fever and purulent drainage. Approximately 50% of all older adults with infections will develop vague symptoms such as anorexia, fatigue, weakness, or change in mental status. Constipation is not noted for stimulating mental status changes. Loss of hearing from malfunctioning hearing aids is most likely to cause difficulties of communication.
A cytotechnologist is performing genetic testing on a series of tissues. One tissue comes back with the WT1 mutation, and it's mapped to chromosome 11. What disease will the client most likely develop? Wilms tumor Renal cell carcinoma Pyelonephritis Alport syndrome
Wilms tumor EXPLANATION: Wilms tumor gene, WT1, which is located on chromosome 11, encodes a transcription factor that is critical for normal kidney development. Roughly 20% of all Wilms tumors carry WT1 mutations. Renal cell carcinoma is a different mutation, as is Alport syndrome. Pyelonephritis is an infection.
The nurse recognizes the most common cause of acute postinfectious glomerulonephritis as: a streptococcal infection 7 to 12 days prior to onset. prolonged blockage of the ureter with a stone. drug-induced damage to the renal glomeruli. uncontrolled diabetes with increased proteinuria.
a streptococcal infection 7 to 12 days prior to onset EXPLANATION: Acute postinfectious glomerulonephritis usually occurs after infection with certain strains of group A beta-hemolytic streptococci and is caused by deposition of immune complexes. It also may occur after infections by other organisms, including staphylococci and a number of viral agents, such as those responsible for mumps, measles, and chickenpox.
A nurse is caring for a client with diabetic glomerulosclerosis. The presence of which substance in the urine would be used in diagnosing this condition? albumin potassium sodium hemoglobin
albumin EXPLANATION: Microalbuminuria is an important predictor of future diabetic nephropathies and is evidence of glomerular damage. Normally, albumin as a large protein molecule, should not be passed through the glomerular filtration process. Microalbuminuria is defined as urinary albumin excretion of 30 to 300 mg in 24 hours. Presence of electrolytes or hemoglobin is not evidence of diabetic glomerulosclerosis.
The initiating event in the development of nephrotic syndrome is a derangement in the glomerular membrane that causes increased permeability to which substance? Red blood cells Plasma proteins Inflammatory cells Antibody complexes
Plasma Proteins EXPLANATION: The initiating event in the development of nephrotic syndrome is a derangement in the glomerular membrane that causes increased permeability to plasma proteins. Some of nephrotic glomerular injury results from circulating antigen-antibody complexes that become trapped in the glomerular membrane. The nephritic syndromes are characterized by hematuria with red cell casts.
If a client is in the early phases of nephrotic syndrome, which area of the body will likely have the initial presence of edema? Lower extremities Abdomen Eyelids Hands
Lower extremities EXPLANATION: Initially, the edema caused by nephritic syndrome presents in the dependent parts of the body, such as the lower extremities, but becomes more generalized as the disease progresses.
A client diagnosed with Goodpasture syndrome would require which therapy to remove proteins and autoantibodies from the system? Plasmapheresis Kidney removal Renal transplant Intravenous calcium
Plasmapheresis EXPLANATION: Plasmapheresis is used to filter the blood for removal of proteins and the circulating anti-GBM antibodies. Renal transplantation would return the kidneys to normal function, but this is the extreme of treatment. The other options would not produce the necessary treatment outcomes
The nurse is reviewing the laboratory results for a client. Which laboratory findings would the nurse correlate with nephrotic syndrome? elevated urine protein level (>3.5 g/day) and hypoalbuminemia low triglycerides (<150 mg/dl; 1.69 mmol/l) and elevated sodium levels low platelet level (<20 ×103/µl; 20 ×109/l) and elevated blood pressure decreased high-density lipoproteins (HDL) and increased hemoglobin levels (Hgb >18 g/dl; 180 g/l).
elevated urine protein level (>3.5 g/day) and hypoablbuminemia EXPLANATION: Nephrotic syndrome results from glomerular disease. The increase in glomerular permeability leads to loss of protein and fat into the urine. The loss of protein leads to low albumin levels, which result in edema. Nephrotic syndrome has no direct effect on platelet or hemoglobin levels. Low plasma sodium levels (hyponatremia) is more common in nephrotic syndrome due to fluid retention.
The nurse is caring for a client with recurring urinary tract infections (UTIs). The client asks, "Other than taking antibiotics, what else can I do?" Which response by the nurse is most accurate? Drink lots of fluids to help relieve the signs/symptoms of UTIs. Eat plenty of yogurt that contains protein to prevent future infection. Include lots of calcium in your diet to promote urinary health. Monitor and limit your intake of fats, especially triglycerides in your diet.
Drink lots of fluids to help relieve the signs/symptoms of UTIs EXPLANATION: Forcing fluids may relieve signs and symptoms, and this approach is used as an adjunct to antimicrobial treatment. The only cure for recurrent lower UTIs is by removing the infectious source like urinary catheter or infected bladder stones.
Most common uncomplicated urinary tract infections are caused by ____ that enter through the urethra. Pseudomonas Escherichia coli Staphylococcus aureus Group B Streptococcus
Escherichia Coli EXPLANATION: Most commonly, urinary tract infections (UTIs) are caused by Escherichia coli bacteria that enter through the urethra. Other uropathic pathogens include Staphylococcus saprophyticus in uncomplicated UTIs, and both non-E. coli Gram-negative rods (Proteus mirabilis, Klebsiella pneumoniae, Pseudomonas) and Gram-positive cocci (Staphylococcus aureus, Group B Streptococcus) in complicated UTIs.
Which of the following clients is at greatest risk for developing a urinary tract infection (UTI)? Male client 2 days postoperative hip fracture repair whose Foley catheter was removed on postoperative day 1 Older adult female client admitted with an indwelling Foley catheter that has been in place for 1 month Woman who has just given birth and had a straight urinary catheter inserted prior to delivery Middle-aged male client admitted for dehydration due to strenuous exercise in hot weather
Older adult female client admitted with an indwelling Foley catheter that has been in place for 1 month EXPLANATION: Urinary catheters are a source of urethral irritation and provide a means for entry of microorganisms into the urinary tract. Catheter-associated bacteriuria remains the most frequent cause of Gram-negative septicemia in hospitalized clients. A catheter in place for 1 month places the client at greatest risk for a UTI.
A client is being treated for calcium oxalate kidney stones. The nurse will include which intervention in the client's care? Select all that apply. Straining urine Administering calcium carbonate Monitoring daily weight Administering loop diuretic Increasing fluid intake
Straining urine Administering calcium carbonate Increasing fluid intake EXPLANATION: Clients with calcium oxalate crystals have excess oxalate levels. Calcium salts such as calcium carbonate bind oxalate in the intestine and decrease its absorption. Thiazide diuretics, not loop diuretics, are used to lower urinary calcium. Loop diuretics increase the amount of calcium in urine. The nurse should strain the client's urine to identify stones that are passed and encourage increased fluid intake to promote dilution of urine. Daily weights are not needed for the client with renal calculi.
A child has been brought to an urgent care clinic. The parents state that the child is "not making water." When taking a history, the nurse learns the child had a sore throat about 1 week ago but seems to have gotten over it. "We [parents] only had to give antibiotics for 3 days for the throat to be better." The nurse should suspect the child has developed: acute renal failure. kidney stones. acute postinfectious glomerulonephritis. nephrotic syndrome.
acute postinfectious glomerulonephritis EXPLANATION: The classic case of poststreptococcal glomerulonephritis follows a streptococcal infection by approximately 7 to 12 days: the time needed for the development of antibodies. The primary infection usually involves the pharynx (pharyngitis), but can also result from a skin infection (impetigo). Oliguria, which develops as the GFR decreases, is one of the first symptoms.
The nurse assesses a client in an ambulatory care facility. Which manifestation(s) leads the nurse to advocate for investigation of possible acute pyelonephritis? Select all that apply. flank pain in the back abrupt onset of fever and chills heart palpitations shortness of breath urinary urgency and frequency
flank pain in the back abrupt onset of fever and chills urinary urgency and frequency EXPLANATION: Acute pyelonephritis tends to present with an abrupt onset of chills, high fever, and an ache or tenderness in the flank area of the back. Lower urinary tract symptoms—dysuria, frequency, and urgency—also are common. Nausea and vomiting may occur along with abdominal pain. Heart palpitations and shortness of breath are specific to acute pyelonephritis, so would not be used as evidence to support further investigation for this condition.
The nurse is evaluating the urinalysis results of a client presenting with polyuria and lower abdominal pain due to a suspected urinary tract infection (UTI). Which finding should the nurse report as evidence of a UTI? increased nitrites positive glucose specific gravity of 1.025 solid formations
increased nitrites EXPLANATION: The nurse would expect the urinalysis of a client with a UTI to have increased nitrites. Bacteria reduce (i.e., break down) nitrates in the urine into nitrites; therefore, increased nitrite levels support bacterial activity. Glucose and protein are not normal findings associated with a UTI and would require follow-up. Specific gravity of 1.025 is within normal limits, which may be present in a UTI but does not support its diagnosis; solid formations in the urine suggest calculi.
A major complication of prolonged bed rest is an increased risk of kidney stones. The nurse knows that this is most likely related to: saturation of urine with calcium salts. a limited access to fluids while hospitalized. increased urine levels of citrate. frequency of urination.
saturation of urine with calcium salts EXPLANATION: Prolonged immobility leads to bone resorption and an elevation in serum calcium which can cause the development of calcium-containing kidney stones. Elevated urine levels of citrate are a prominent inhibitor of calcium stone formation. Fluid intake is not likely to be limited but regardless, it would not contribute to kidney stone formation. Urinary frequency is not a factor in kidney stone formation.