Patho Renal ch 26

Proteinuria is characteristic of what type of kidney disease?

Glomerular disease (Nephron damage)

A client who has developed stage 3 renal failure has been diagnosed with high phosphate levels. To avoid the development of osteodystrophy, the physician may prescribe a phosphate-binding agent that does not contain: A. Aluminum B. Calcium carbonate C. Calcium acetate D. Sevelamer hydrochloride

A Aluminum-containing antacids can contribute to the development of osteodystrophy, whereas calcium-containing phosphate binders can lead to hypercalcemia, thus worsening soft tissue calcification, especially in persons receiving vitamin D therapy. Sevelamer hydrochloride is a newer phosphate-binding agent that does not contain calcium or aluminum.

An 86-year-old female client has been admitted to the hospital for the treatment of dehydration and hyponatremia after she curtailed her fluid intake to minimize urinary incontinence. The client's admitting laboratory results are suggestive of prerenal failure. The nurse should be assessing this client for which of the following early signs of prerenal injury? A) Sharp decrease in urine output B) Excessive voiding of clear urine C) Acute hypertensive crisis D) Intermittent periods of confusion

A Dehydration and its consequent hypovolemia can result in acute renal failure that is prerenal in etiology. The kidney normally responds to a decrease in GFR with a decrease in urine output. Thus, an early sign of prerenal injury is a sharp decrease in urine output. Postrenal failure is obstructive in etiology, and intrinsic (or intrarenal) renal failure is reflective of deficits in the function of the kidneys themselves.

A client with a diagnosis of chronic kidney disease (CKD) may require the administration of which of the following drugs to treat coexisting conditions that carry a high mortality? A. Antihypertensive medications B. Antiarrhythmic medications C. Opioid analgesics D. Nonsteroidal anti-inflammatory drugs (NSAIDs)

A Hypertension is a common result of CKD, and the mechanisms that produce hypertension in CKD include increased vascular volume, elevation of peripheral vascular resistance, decreased levels of renal vasodilator prostaglandins, and increased activity of the renin-angiotensin-aldosterone system. NSAIDs, opioids, and antiarrhythmics are not as frequently indicated for the treatment of CKD.

A drug abuser was found unconscious after shooting up heroin 2 days prior. Because of the pressure placed on the hip and arm, the client has developed rhabdomyolysis. The nurse knows this can: A) Obstruct the renal tubules with myoglobin and damage tubular cells B) Be cured by administering an anticoagulant immediately C) Cause the kidney to develop renal stones due to stasis D) Cause compartment syndrome in the lower extremities

A Myoglobin normally is not found in the serum or urine. It has a low molecular weight; if it escapes into the circulation, it is rapidly filtered in the glomerulus. A life-threatening condition known as rhabdomyolysis occurs when increasing myoglobinuria levels cause myoglobin to precipitate in the renal tubules, leading to obstruction and damage to surrounding tubular cells. Myoglobinuria most commonly results from muscle trauma but may result from exertion, hyperthermia, sepsis, prolonged seizures, and alcoholism or drug abuse. Rhabdomyolysis is not cured with anticoagulation administration nor does it cause kidney stones. Compartment syndrome occurs when there is insufficient blood supply to muscles and nerves due to increased pressure within one of the body's compartments.

A client with a recent diagnosis of renal failure who will require hemodialysis is being educated in the dietary management of the disease. Which of the client's following statements shows an accurate understanding of this component of treatment? A. "I've made a list of high-phosphate foods, so that I can try to avoid them." B. "I'm making a point of trying to eat lots of bananas and other food rich in potassium." C. "I'm going to try to maintain a high-fiber, low-carbohydrate diet." D. "I don't think I've been drinking enough, so I want to include 8 to 10 glasses of water each day."

A Persons with chronic kidney disease (CKD) are usually encouraged to limit their dietary phosphorus as a means of preventing secondary hyperparathyroidism, renal osteodystrophy, and metastatic calcification. Excessive potassium and fluids are likely contraindicated in kidney disease individuals require hemodialysis. The amount of dietary fiber intake is not a priority when looking at primary needs of a CKD patient's food intake.

While assessing a peritoneal dialysis client in his or her home, the nurse notes that the fluid draining from the abdomen is cloudy, is white in color, and contains a strong odor. The nurse suspects this client has developed a serious complication known as: A. Peritonitis B. Bowel perforation C. Too much sugar in the dialysis solution D. Bladder erosion

A Potential problems with peritoneal dialysis include infection, catheter malfunction, dehydration, hyperglycemia, and hernia. Bowel perforation can occur, but the fluid would be stool colored. The client may develop hyperglycemia; however, this will not cause the fluid to be cloudy. If bladder erosion had occurred, the fluid would look like urine and not be cloudy and white.

14. A chronic kidney disease client who has renal osteodystrophy should be assessed for which of the following complications? Select all that apply. A. Muscle weakness B. Kidney stones C. Bone pain D. Stress fractures E. Urosepsis

A, C, D Both types of renal osteodystrophy are manifested by abnormal absorption and defective bone remodeling. Renal osteodystrophy is typically accompanied by reductions in bone mass, alterations in bone microstructure, bone pain, and skeletal fracture. There are changes in bone turnover, mineralization, and bone volume, accompanied by bone pain and muscle weakness, risk of fractures, and other skeletal complications. Kidney stones and urosepsis are not associated with renal osteodystrophy.

7. When acute tubular necrosis (ATN) is suspected, the nurse will likely see which of the following laboratory findings on the urinalysis report? Select all that apply. A. Protein B. Glucose C. Red blood cells D. Sodium excess E. Cast cells

A, C, E Nephron damage allows the larger protein cells to pass through the membrane and into the urine (normally, urine has very few proteins present). Further diagnostic information that can be obtained from the urinalysis includes hemoglobinuria (blood in the urine) and casts or crystals in the urine. Glucosuria in the urine is an indirect indication of extreme hyperglycemia, often unrelated to renal disease. Urine sodium concentration is maintained with prerenal azotemia; urine sodium decreases with renal tubule damage. Urine calcium is not diagnostic for ATN.

If a CKD client is developing uremic encephalopathy, the earliest manifestations may include: Select all that apply. A. Decreased alertness B. Delirium and hallucinations C. New-onset seizures D. Diminished awareness

A, D Reductions in alertness and awareness are the earliest and most significant indications of uremic encephalopathy. Late in the disease process, the client may develop delirium, coma, and seizures.

As nitrogenous wastes increase in the blood, the CKD client may exhibit which of the following clinical manifestations? Select all that apply. A. Numbness in lower extremities B. Photophobia C. Extremely low platelet counts D. Restless leg syndrome E. Pruritis

A, D, E The uremic state is characterized by signs and symptoms of altered neuromuscular function (e.g., fatigue, peripheral neuropathy, restless leg syndrome, sleep disturbances, uremic encephalopathy); gastrointestinal disturbances such as anorexia and nausea; white blood cell and immune dysfunction, and dermatologic manifestations such as pruritus. Photophobia and thrombocytopenia are usually not associated with CKD.

As chronic kidney disease progresses, the second stage (renal insufficiency) is identified by: A. Decrease in GFR of 60 to 89 mL/minute/1.73 m2 B. Decrease in GFR to 30 to 59 mL/minute/1.73 m2 C. GFR decrease to 15 to 29 mL/minute/1.73 m2 D. Diminished GFR to less than 15 mL/minute/1.73 m2

A. Diminished renal reserve is characteristic of renal insufficiency, when labs remain normal but there is renal insufficiency. Only the second stage, formerly known as renal insufficiency, is characterized by a decrease in GFR of 60 to 89 mL/minute/1.73 m2. The other choices represent stage 3, 4, and 5, respectfully.

Why shouldn't CKD patients take antacids containing Aluminum?

Aluminum can contribute to the development of osteodystrophy.

24. Manifestations of childhood renal disease are varied and may differ from adult-onset renal failure. A school-aged child with chronic kidney disease may exhibit: A. Low IQ level with borderline retardation B. Developmental delays such as uncoordinated gait and minimal fine motor skills C. Inability to control bladder, resulting in incontinence D. Frequent, uncontrolled rolling of the tongue and opening mouth extremely wide

B Childhood chronic kidney disease is manifested by growth and developmental delays and late onset sexual maturity as a result of the uremic effects on endocrine function, bone abnormalities, and development of psychosocial problems. Renal failure is unrelated to the ability of children to have control of urine or bowel elimination. Intelligence is not affected by renal failure, although renal encephalopathy may affect behavior.

A client with significant burns on his lower body has developed sepsis on the 3rd day following his accident. Which of the following manifestations would the nurse anticipate for an ischemic acute tubular necrosis rather than prerenal failure? The client: A) Exhibits pulmonary and peripheral edema B) GFR does not increase after restoration of renal blood flow C) Undergoes emergent hemodialysis that does not result in decreased BUN and creatinine D) Exhibits oliguria and frank hematuria

B In contrast to prerenal failure, the glomerular filtration rate (GFR) does not improve with the restoration of renal blood flow in acute renal failure caused by ischemic acute tubular necrosis. Edema, oliguria, and hematuria are not diagnostic of acute tubular necrosis (ATN), and hemodialysis does not normally fail to achieve a reduction in blood urea nitrogen (BUN) and creatinine.

Reduced glomerular filtration rate (GFR), with a serum creatinine level that remains in the normal range, is associated with aging because elderly persons tend to have reduced: A. Calcium intake B. Muscle mass C. Drug tolerance D. Renal perfusion

B Serum creatinine level is directly related to muscle metabolism. Because muscle mass is reduced in elderly persons, the creatinine level does not increase as readily with a lower GFR. Drug tolerance and renal perfusion can affect the GFR, but the age-related normal creatinine level can also be present. Calcium intake is unrelated to creatinine levels or GFR.

A client is beginning to recover from acute tubular necrosis. The nurse would likely be assessing which of the following manifestations of the recovery phase of ATN? A) Edema B) Diuresis C) Proteinuria D) Hypokalemia

B The recovery phase is first noticed as increased/excessive output (diuresis) of dilute urine and a fall in serum creatinine, indicating that the nephrons have recovered to the point at which urine excretion is possible. Potassium will remain elevated or continue to rise, since the diuresis occurs before renal function fully returns to normal. Edema/fluid retention is characteristic of the maintenance phase. Proteinuria is characteristic of glomerular disease and/or chronic kidney disease.

A diabetic client with a history of hypertension may receive a prescription for which medication to provide a renal protective effect by reducing intraglomerular pressure? Select all that apply. A) Loop diuretics B) ACE inhibitors C) Angiotensin receptor blockers D) Calcium channel blockers E) A digitalis preparation

B, C The ACE inhibitors and ARBs reduce the effects of angiotensin II on renal blood flow. They also reduce intraglomerular pressure and may have a renal protective effect in persons with hypertension or type 2 diabetes. However, when combined with diuretics, they may cause prerenal injury in persons with decreased blood flow due to large-vessel or small-vessel kidney disease. Calcium channel blockers are vasodilators.

19. A chronic kidney disease (CKD) client asks the nurse, "Why do I itch all the time?" The nurse bases her response on which of the following integumentary physiologic factors that causes pruritis? Select all that apply. A. Too harsh of soap while bathing B. Decrease in perspiration C. Limited sodium intake D. Enlarged size of sweat glands E. Elevated serum phosphate levels

B, E Dry, itchy skin is a common consequence of CKD. Pruritus is common; it results from the high serum phosphate levels and the development of phosphate crystals that occur with hyperparathyroidism. Harsh soap (may dry the skin), limited Na+ intake, and enlarged sweat glands are not noted to accompany or result in pruritus.

Regardless of the cause, chronic kidney disease results in progressive permanent loss of nephrons and glomerular filtration, and renal: A. Tubule dysplasia B. Vascular pressure C. Endocrine functions D. Hypophosphatemia

C Chronic kidney disease results in loss of nephrons, tubule, and endocrine functions such as erythropoietin production. Systemic and renal hypertension is commonly an early manifestation of chronic kidney disease, caused by resistance to blood flow through the constricted renal vessels. Tubule hypertrophy is a compensatory response for those destroyed—when the few remaining nephrons are destroyed, renal failure is apparent. Phosphate accumulates in the blood; since it is inversely related to calcium, the levels of which remain chronically low.

The nurse is providing care for a client who has a diagnosis of kidney failure. Which of the following laboratory findings is consistent with this client's diagnosis? A. Elevation in vitamin D levels B. Hypophosphatemia C. Hypocalcemia D. Hypokalemia

C Diagnostic findings that are congruent with a diagnosis of kidney failure include hyperphosphatemia, hypocalcemia, a decrease in active vitamin D levels, and secondary hyperparathyroidism.

The primary care provider for a newly admitted hospital client has added the glomerular filtration rate (GFR) to the blood work scheduled for this morning. The client's GFR results return as 50 mL/minute/1.73 m2. The nurse explains to the client that this result represents: A. A need to increase water intake B. The kidneys are functioning normally C. A loss of over half the client's normal kidney function D. Concentrated urine

C In clinical practice, GFR is usually estimated using the serum creatinine concentration. A GFR below 60 mL/minute/1.73 m2 represents a loss of one half or more of the level of normal adult kidney function. The GFR is not diagnostic for concentrated urine or the need to drink more water.

A client had excessive blood loss and prolonged hypotension during surgery. His postoperative urine output is sharply decreased, and his blood urea nitrogen (BUN) is elevated. The most likely cause for the change is acute: A) Prerenal inflammation B) Bladder outlet obstruction C) Tubular necrosis D) Intrarenal nephrotoxicity

C Ischemic acute tubular necrosis (ATN) occurs most frequently in persons who have major surgery with prolonged renal hypoperfusion—this directly damages the tubular epithelial cells with acute suppression of renal function. Nephrotoxic ATN is caused by toxic agents or drugs. Prerenal vasoconstriction is associated with acute-onset loss of renal output. Bladder (postrenal) obstruction would not affect the BUN, since it rarely causes renal failure.

Client and family education regarding peritoneal dialysis should include assessing the client for: A. Bleeding around the arteriovenous fistula or an external arteriovenous shunt B. Signs and symptoms of hypoglycemia such as weakness, irritability, and shakiness C. Dehydration that may appear as dry mucous membranes or poor skin turgor D. Muscle cramps associated with hypoparathyroidism

C Potential problems with peritoneal dialysis include infection, catheter malfunction, dehydration caused by excessive fluid removal, hyperglycemia, and hernia. The most serious complication is infection, which can occur at the catheter exit site, in the subcutaneous tunnel, or in the peritoneal cavity. In peritoneal dialysis, a sterile dialyzing solution is instilled through a catheter over a period of approximately 10 minutes. Then the solution is allowed to remain in the peritoneal cavity for a prescribed amount of time. Shunts, fistulas, and artificial dialyzers are associated with hemodialysis, which is usually performed three times weekly.

A client with a long-standing diagnosis of chronic kidney disease has been experiencing increasing fatigue, lethargy, and activity intolerance in recent weeks. His care team has established that his GFR remains at a low, but stable, level. Which of the following assessments is most likely to inform a differential diagnosis? A. Blood work for white cells and differential B. Cystoscopy and ureteroscopy C. Assessment of pancreatic exocrine and endocrine function D. Blood work for hemoglobin, red blood cells, and hematocrit

D Anemia is a frequent, and debilitating, consequence of CKD. The anemia may be due to chronic blood loss, hemolysis, bone marrow suppression due to retained uremic factors, and decrease in red cell production due to impaired production of erythropoietin and iron deficiency. Pancreatic function is not typically affected by CKD, and endoscopic examination is less likely to reveal a cause of fatigue. An infectious etiology is possible and would be informed by white cell assessment, but this is less likely than anemia given the client's complaints.

Impaired skin integrity and skin manifestations are common in persons with chronic kidney disease. Pale skin and subcutaneous bruising are often present as a result of: A. Thrombocytopenia B. Anticoagulant therapy C. Decreased vascular volume D. Impaired platelet function

D Bruising and pale skin are present with chronic kidney disease because platelet function is impaired. Adequate platelets are available, but the function is abnormal. Renal clients do not routinely receive anticoagulant therapy, since they already have bleeding tendencies. Increased vascular volume is associated with renal disease.

8. Which of the following individuals likely faces the greatest risk for the development of chronic kidney disease? A. A first-time mother who recently lost 1.5 L of blood during a postpartum hemorrhage B. A client whose diagnosis of thyroid cancer necessitated a thyroidectomy C. A client who experienced a hemorrhagic stroke and now has sensory and motor deficits D. A client with a recent diagnosis of type 2 diabetes who does not monitor his blood sugars or control his diet

D Chronic kidney disease (CKD) is a pathophysiologic process that results in the loss of nephrons and a decline in renal function that has persisted for more than 3 months. CKD can result from diabetes, hypertension, glomerulonephritis, lupus (SLE), and polycystic kidney disease. The prevalence and incidence of CKD continue to grow, reflecting the growing elderly population and the increasing number of people with diabetes and hypertension. Hemorrhage may result in acute renal failure, but it is not associated with chronic kidney disease. Stroke and loss of the thyroid gland are not noted to underlie cases of chronic kidney disease.

Why is Sevelamer prescribed to CKD patients?

Phosphate binder that does not contain calcium or aluminum

Why is hyperglycemia a complication of peritoneal dialysis?

The dialysate is a hypertonic glucose solution

Serum Creatinine level is directly related to_____________ metabolism

muscle