Test 3 (Final) - Chapter 26: The Child with Genitourinary Dysfunction

ANS: A, C, E

1. The nurse is caring for a 4-year-old girl with a history of frequent urinary tract infections (UTIs). What should the nurse be aware of before obtaining a urine sample? Select all that apply. a. To obtain a clean-catch urine specimen, have the child sit on the toilet facing backward toward the tank. b. Because children who have a UTI will have painful urination, have the child drink a large amount of fluid before obtaining the sample. c. The specimen must be fresh—less than 1 hour after voiding with storage at room temperature or less than 4 hours after voiding with refrigeration. d. If a urinalysis obtained by a bag specimen is negative, a specimen still needs to be obtained by catheterization or suprapubic aspiration. e. The key to distinguishing a true UTI from asymptomatic bacteriuria is the presence of pyuria. f. Because the child is febrile, the nurse should immediately start an antimicrobial and then obtain a urine culture.

ANS: A, B, D

2. A child with periorbital edema, decreased urine output, pallor, and fatigue is admitted to the pediatric unit. The child is being examined for acute glomerular nephritis. Which of the following nursing measures should be considered? Select all that apply. a. On examination, there is usually a mild to moderate elevation in blood pressure compared with normal values for age, although severe hypertension may be present. b. Urinalysis during the acute phase characteristically shows hematuria, proteinuria, and increased specific gravity, c. The primary objective is to reduce the excretion of urinary protein and maintain protein-free urine. d. Assessment of the child's appearance for signs of cerebral complications is an important nursing function because the severity of the acute phase is variable and unpredictable. e. Because these children are particularly vulnerable to upper respiratory tract infection, protect them from contact with infected roommates, family, or visitors.

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. Page 851 Nursing Care Guidelines Prevention of Urinary Tract Infection Factors Predisposing to Development Short female urethra close to vagina and anus Incomplete emptying and overdistention of bladder Concentrated urine Constipation Measures of Prevention Practice perineal hygiene; wipe from front to back. Avoid tight clothing or diapers; wear cotton panties rather than nylon. Avoid "holding" urine; encourage child to void frequently. Take time to empty bladder completely. This may be helped by relaxed toilet posture for girls, with feet supported on a stool and knees apart. Some children benefit from "double voiding" (void, wait a few minutes, and void again). Avoid constipation. Encourage adequate fluid intake.

4. What name is given to inflammation of the bladder? a. Cystitis b. Urethritis c. Urosepsis d. Bacteriuria

ANS: A Cystitis is an inflammation of the bladder. Urethritis is an inflammation of the urethra. Urosepsis is a febrile urinary tract infection with systemic signs of bacterial infection. Bacteriuria is the presence of bacteria in the urine.

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). Page 845 Classification Infection of the urinary tract may be present with or without clinical symptoms. As a result, the site of infection is often difficult to pinpoint with any degree of accuracy. Various terms used to describe urinary tract disorders include: Bacteriuria: Presence of bacteria in the urine Pyuria: Presence of white blood cells in the urine Asymptomatic bacteriuria: Significant bacteriuria (usually defined as >100,000 colony-forming units [CFUs]) with no evidence of clinical infection Symptomatic bacteriuria: Bacteriuria accompanied by physical signs of UTI (dysuria, suprapubic discomfort, hematuria, fever) Recurrent UTI: Repeated episode of bacteriuria or symptomatic UTI Persistent UTI: Persistence of bacteriuria despite antibiotic treatment Febrile UTI: Bacteriuria accompanied by fever and other physical signs of UTI; presence of a fever typically implies pyelonephritis Cystitis: Inflammation of the bladder Urethritis: Inflammation of the urethra Pyelonephritis: Inflammation of the upper urinary tract and kidneys Urosepsis: Febrile UTI coexisting with systemic signs of bacterial illness; blood culture reveals presence of urinary pathogen.

4. When giving discharge instructions to a parent post hypospadias repair, the nurse recognizes a need for more teaching when the mother says which of the following? Select all that apply. a. "I know that I should never clamp off the catheter." b. "My child can take a tub bath when we arrive home because it will soothe the area." c. "An antibacterial ointment may be applied to the penis daily for infection control." d. "Fluids should be monitored and rationed to prevent fluid overload." e. "My child should avoid straddle toys, sandboxes, swimming, and rough activities until allowed by the surgeon."

ANS: A, C, E

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. Page 850 Box 26-1 Clinical Manifestations of Urinary Tract Disorders or Disease Neonatal Period (Birth to 1 Month Old) Poor feeding Vomiting Failure to gain weight Rapid respiration (acidosis) Respiratory distress Spontaneous pneumothorax or pneumomediastinum Frequent urination Screaming on urination Poor urine stream Jaundice Seizures Dehydration Other anomalies or stigmata Enlarged kidneys or bladder Infancy (1 to 24 Months Old) Poor feeding Vomiting Failure to gain weight Excessive thirst Frequent urination Straining or screaming on urination Foul-smelling urine Pallor Fever Persistent diaper rash Seizures (with or without fever) Dehydration Enlarged kidneys or bladder Childhood (2 to 14 Years Old) Poor appetite Vomiting Growth failure Excessive thirst Enuresis, incontinence, frequent urination Painful urination Swelling of face Seizures Pallor Fatigue Blood in urine Abdominal or back pain Edema Hypertension Tetany

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.

11. What measure of fluid balance status is most useful in a child with acute glomerulonephritis? a. Proteinuria b. Daily weight c. Specific gravity d. Intake and output

ANS: B A record of daily weight is the most useful means to assess fluid balance and should be kept for children treated at home or in the hospital. Proteinuria does not provide information about fluid balance. Specific gravity does not accurately reflect fluid balance in acute glomerulonephritis. If fluid is being retained, the excess fluid will not be included. Also proteinuria and hematuria affect specific gravity. Intake and output can be useful but are not considered as accurate as daily weights. In children who are not toilet trained, measuring output is more difficult.

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 B-hemolytic streptococcus. Acute glomerulonephritis usually follows streptococcal pharyngitis and is not associated with renal vascular disorders or genitourinary tract structural anomalies. Page 861 Acute Glomerulonephritis Acute glomerulonephritis (AGN) may be a primary event or a manifestation of a systemic disorder that can range from minimal to severe. Common features include oliguria, edema, hypertension and circulatory congestion, hematuria, and proteinuria. Most cases are postinfectious and have been associated with pneumococcal, streptococcal, and viral infections. Acute poststreptococcal glomerulonephritis (APSGN) is the most common of the postinfectious renal diseases in childhood and the one for which a cause can be established in the majority of cases. APSGN can occur at any age but affects primarily early school-age children, with a peak age of onset of 6 to 7 years old. It is uncommon in children younger than 2 years old, and boys outnumber girls two to one.

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.

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. Page 860 Therapeutic Management Objectives of therapeutic management include (1) reducing excretion of urinary protein, (2) reducing fluid retention in the tissues, (3) preventing infection, and (4) minimizing complications related to therapies. Dietary restrictions include a low-salt diet and, in more severe cases, fluid restriction. If complications of edema develop, diuretic therapy may be initiated to provide temporary relief from edema. Sometimes infusions of 25% albumin are used. Acute infections are treated with appropriate antibiotics.

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. Page 851 Nursing Care Guidelines Prevention of Urinary Tract Infection Factors Predisposing to Development Short female urethra close to vagina and anus Incomplete emptying and overdistention of bladder Concentrated urine Constipation Measures of Prevention Practice perineal hygiene; wipe from front to back. Avoid tight clothing or diapers; wear cotton panties rather than nylon. Avoid "holding" urine; encourage child to void frequently. Take time to empty bladder completely. This may be helped by relaxed toilet posture for girls, with feet supported on a stool and knees apart. Some children benefit from "double voiding" (void, wait a few minutes, and void again). Avoid constipation. Encourage adequate fluid intake.

15. A child is admitted with acute glomerulonephritis. What should the nurse expect the urinalysis to show during the acute phase? 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. Page 861 Acute Glomerulonephritis Acute glomerulonephritis (AGN) may be a primary event or a manifestation of a systemic disorder that can range from minimal to severe. Common features include oliguria, edema, hypertension and circulatory congestion, hematuria, and proteinuria. Most cases are postinfectious and have been associated with pneumococcal, streptococcal, and viral infections. Acute poststreptococcal glomerulonephritis (APSGN) is the most common of the postinfectious renal diseases in childhood and the one for which a cause can be established in the majority of cases. APSGN can occur at any age but affects primarily early school-age children, with a peak age of onset of 6 to 7 years old. It is uncommon in children younger than 2 years old, and boys outnumber girls two to one.

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. Page 858 Box 26-2 Clinical Manifestations of Nephrotic Syndrome Weight gain Puffiness of face (facial edema): • Especially around the eyes • Apparent on arising in the morning • Subsides during the day Abdominal swelling (ascites) Pleural effusion Labial or scrotal swelling Edema of intestinal mucosal, possibly causing: • Diarrhea • Anorexia • Poor intestinal absorption Ankle or leg swelling Irritability Easily fatigued Lethargic Blood pressure normal or slightly decreased Susceptibility to infection Urine alterations: • Decreased volume • Frothy

12. The parent of a child hospitalized with acute glomerulonephritis asks the nurse why blood pressure readings are being taken so often. What knowledge should influence the nurses reply? a. The antibiotic therapy contributes to labile blood pressure values. b. Hypotension leading to sudden shock can develop at any time. c. Acute hypertension is a concern that requires monitoring. d. Blood pressure fluctuations indicate that the condition has become chronic.

ANS: C Blood pressure monitoring is essential to identify acute hypertension, which is treated aggressively. Antibiotic therapy is usually not indicated for glomerulonephritis. Hypertension, not hypotension, is a concern in glomerulonephritis. Blood pressure control is essential to prevent further renal damage. Blood pressure fluctuations do not provide information about the chronicity of the disease. Page 861 Acute, sometimes severe, hypertension must be anticipated and identified early. Blood pressure measurements are taken every 4 to 6 hours. A variety of antihypertensive medications and diuretics are used to control hypertension.

16. The nurse is teaching a child experiencing severe edema associated with minimal change nephrotic syndrome about his diet. The nurse should discuss what dietary need? a. Consuming a regular diet b. Increasing protein c. Restricting fluids d. Decreasing calories

ANS: C During the edematous stage of active nephrosis, the child has restricted fluid and sodium intake. As the edema subsides, the child is placed on a diet with increased salt and fluids. A regular diet is not indicated. There is no evidence that a diet high in protein is beneficial or has an effect on the course of the disease. Calories sufficient for growth and tissue healing are essential. With the child having little appetite and the fluid and salt restrictions, achieving adequate nutrition is difficult. Page 859 The diagnosis of MCNS is suspected on the basis of the history and clinical manifestations (edema, proteinuria, hypoalbuminemia, and hypercholesterolemia in the absence of hematuria and hypertension) in children between 2 and 8 years old. The hallmark of MCNS is massive proteinuria (higher than 2+ on urine dipstick).

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.

8. In teaching the parent of a newly diagnosed 2-year-old child with pyelonephritis related to vesicoureteral reflux (VUR), the nurse should include which information? a. Limit fluids to reduce reflux. b. Give cranberry juice twice a day. c. Have siblings examined for VUR. d. Surgery is indicated to reverse scarring.

ANS: C Siblings are at high risk for VUR. The incidence of reflux in siblings is approximately 36%. The other children should be screened for early detection and to potentially reduce scarring. Fluids are not reduced. The efficacy of cranberry juice in reducing infection in children has not been established. Surgery may be necessary for higher grades of VUR, but the scarring is not reversible.

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. What is most likely the cause of the weight loss? 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.

5. The nurse is teaching a client to prevent future urinary tract infections (UTIs). What factor is most important to emphasize as the potential cause? a. Poor hygiene b. Constipation c. Urinary stasis d. Congenital anomalies

ANS: C Urinary stasis is the single most important host factor that influences the development of UTIs. Urine is usually sterile but at body temperature provides an excellent growth medium for bacteria. Poor hygiene can be a contributing cause, especially in females because their short urethras predispose them to UTIs. Urinary stasis then provides a growth medium for the bacteria. Intermittent constipation contributes to urinary stasis. A full rectum displaces the bladder and posterior urethra in the fixed and limited space of the bony pelvis, causing obstruction, incomplete micturition, and urinary stasis. Congenital anomalies can contribute to UTIs, but urinary stasis is the primary factor in many cases.

16. A mother asks the nurse what would be the first indication that acute glomerulonephritis is improving. What is the nurse's best response? 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. Page 861 Acute Glomerulonephritis Acute glomerulonephritis (AGN) may be a primary event or a manifestation of a systemic disorder that can range from minimal to severe. Common features include oliguria, edema, hypertension and circulatory congestion, hematuria, and proteinuria.

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. A urethral opening along the ventral surface of the penis is known as epispadias. Page 855 Hypospadias is a congenital anomaly of the male urethra that results in abnormal ventral placement of the urethral opening on the underside of the penis, ranging from the glans to the perineum (Fig. 26-3).

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. Page 859 Side effects of the steroids include increased appetite, weight gain, rounding of the face, and behavior changes. Long-term therapy may result in hirsutism, growth retardation, cataracts, hypertension, gastrointestinal bleeding, bone demineralization, infection, and hyperglycemia.

13. What laboratory finding, in conjunction with the presenting symptoms, indicates minimal change nephrotic syndrome? a. Low specific gravity b. Decreased hemoglobin c. Normal platelet count d. Reduced serum albumin

ANS: D Total serum protein concentrations are reduced, with the albumin fractions significantly reduced. Specific gravity is high and proportionate to the amount of protein in the urine. Hemoglobin and hematocrit are usually normal or elevated. The platelet count is elevated as a result of hemoconcentration.

32. 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.