patho renal ch 25

The most common cause of chronic pyelonephritis:

vesicoureteral reflux

Nephrotic syndrome is characterized by

massive proteinuria (looks dark and frothy) caused by glomerular damage. Corticosteroids are the mainstay. Generalized edema common.

A client has recently undergone successful extracorporeal shock wave lithotripsy (ESWL) for the treatment of renal calculi. Which of the following measures should the client integrate into his lifestyle to reduce the risk of recurrence? A. Increased fluid intake and dietary changes B. Weight loss and blood pressure control C. Regular random blood glucose testing D. Increased physical activity and use of over-the-counter diuretics

A Depending on the type of stone that was present, many clients benefit from increased fluid intake and changes in diet. Weight loss, blood sugar and pressure control, and exercise are not central preventative measures. It would likely be inappropriate to recommend the use of over-the-counter diuretics as a preventative measure.

While taking a history from an adult client newly diagnosed with renal cell cancer, the nurse can associate which of the following high-risk factors with the development of this cancer? A. Heavy smoking B. Inherited renal disease C. Adrenal medulla tumors D. Anorexia/bulimia disorder

A Epidemiologic evidence suggests a correlation between heavy smoking and kidney cancer. Obesity also is a risk factor; particularly in women. The risk of renal cell carcinoma also is increased in persons with acquired cystic kidney disease associated with chronic renal insufficiency. Although the adrenal gland is adjacent to the kidney, primary adrenal tumors are unrelated to renal cell disease.

The most recent assessment of a client with a diagnosis of type 1 diabetes indicates a heightened risk of diabetic nephropathy. Which of the following assessment findings is most suggestive of this increased risk? A. Microalbuminuria B. Hematuria C. Orthostatic hypotension D. Diabetic retinopathy

A The increased glomerular filtration rate (GFR) that occurs in persons with early alterations in renal function is associated with microalbuminuria, which is an important predictor of future diabetic nephropathies. Hematuria is not directly suggestive of diabetic nephropathy, although it is a highly significant assessment finding. Orthostatic hypotension and diabetic retinopathy are not direct indicators of diabetic nephropathy.

The most damaging effects of urinary obstruction are the result unrelieved obstruction of urine outflow and: A. Urinary stasis B. Concentrated urine C. Kidney hyperplasia D. Renal hypertension

A The most damaging effects of urinary obstruction are stasis of urine, which predisposes to infection and stone formation, and unrelieved obstruction of urine outflow. Most commonly, the person has pain, signs, and symptoms of urinary tract infection (UTI) and manifestations of renal dysfunction, such as an impaired ability to concentrate urine. Progressive atrophy of the kidney is caused by obstruction of the outflow of urine. Hypertension is an occasional complication of urinary tract obstruction, since urine flow is obstructed rather than renal blood flow.

Which of the following diagnostic and assessment results support the diagnosis of chronic pyelonephritis? Select all that apply. A. Polyuria (excess urine output) B. Nocturia (voiding at night) C. Bilateral flank pain D. Blood pressure 140/92 E. Severe pain in upper outer quadrant of the abdomen

A, B The symptoms of chronic pyelonephritis often include a history of recurrent episodes of UTI or acute pyelonephritis. Loss of tubular function and the ability to concentrate urine give rise to polyuria and nocturia, and mild proteinuria is common. Severe hypertension often is a contributing factor in the progress of the disease. A BP of 140/92 is not considered "severe" hypertension. Flank and upper outer quadrant pain is usually associated with kidney stones.

A client has been recently undergone diagnostic testing for possible Berger disease. The nurse caring for this client would anticipate the primary clinical manifestations include which of the following? Select all that apply. A. Gross hematuria B. Recent upper respiratory infection C. Elevated ketone levels in the urine D. Fever, chills, and general body aches

A, B, D Early in the disease, many people with the disorder have no obvious symptoms, and the disorder is discovered during screening or examination for another condition. In others, the disorder presents with gross hematuria that is preceded by upper respiratory tract infection, GI tract symptoms, or flulike illness. The hematuria lasts 2 to 6 days. Elevated ketones are usually associated with acidosis, fasting, high-protein diet, or diabetes to name a few.

Following the diagnosis of nephrotic syndrome, the nurse knows the clinical manifestations occur as a result of a decreased plasma colloidal osmotic pressure. Therefore, the nurse should assess the client for: Select all that apply. A. Moist crackles in both lung fields B. Areas of diminished breath sounds due to pleural effusions C. Liver enlargement D. Kidneys palpable to deep palpation E. Increased circumference in the abdomen related to fluid excess

A, B, E Generalized edema, which is a hallmark of the nephrotic syndrome, results from a decrease in the plasma colloidal osmotic pressure due to the hypoalbuminemia that develops as albumin is lost from the vascular compartment. Initially, the edema presents in dependent parts of the body such as the lower extremities, but becomes more generalized as the disease progresses. Dyspnea due to pulmonary edema, pleural effusions, and diaphragmatic compromise due to ascites (increase fluid in the abdominal cavity) can develop in persons with nephrotic syndrome. Liver enlargement is not associated with nephrotic syndrome, but increased synthesis of lipoproteins in the liver secondary to a compensatory increase in albumin production may occur. Palpable kidney mass is associated with cancer.

Following an episode of strep throat, the school nurse notices the fourth grade child has not recovered from this illness a week later. Upon further investigation, the nurse notices that the child has developed water retention. Which of the following assessments support this conclusion? Select all that apply. A. Periorbital edema B. BP 100/70 C. Swelling of the hands and fingers D. Vomiting after intake of any solid food E. Dizziness and right ear pain

A, C Generalized edema, a hallmark of nephrosis, results from salt and water retention and a decrease in plasma colloid osmotic pressure due to loss of albumin in the urine. Glomerulonephritis is characterized by sodium and water retention that causes edema, particularly of the face and hands. Fluid retention usually results in an elevated BP, not a normal one. Vomiting and dizziness are not associated with this diagnosis.

If a client with a kidney stone has the "classic" ureteral colic, the client will describe his pain as: Select all that apply. A. Acute, intermittent B. Diffuse over the entire lower back and legs C. Excruciating D. In the flank and upper outer quadrant of the abdomen

A, C, D The symptoms of renal colic are caused by stones 1 to 5 mm in diameter that can move into the ureter and obstruct flow. Classic ureteral colic is manifested by acute, intermittent, and excruciating pain in the flank and upper outer quadrant of the abdomen on the affected side. The pain may radiate to the lower abdominal quadrant, bladder area, perineum, or scrotum in the man. The pain is usually not described as diffuse and over the entire low back and legs.

A client with a history of chronic pyelonephritis has been admitted several times with recurrent bacterial infection of the urinary tract. The nurse should anticipate educating this client with regard to which common treatment regimen? A. Increase intake of cranberry juice to 2 L/day. B. Continue taking antibiotics for full 10 to 14 days even if symptoms of infection disappear. C. Force micturition every 2 hours while awake. D. Take prescribed diuretics early in the day to avoid having to get up during the night.

B Chronic pyelonephritis involves a recurrent or persistent bacterial infection superimposed on urinary tract obstruction, urine reflux, or both. Chronic obstructive pyelonephritis can be bilateral, caused by conditions that obstruct bladder outflow; or unilateral, such as occurs with ureteral obstruction. Cranberry juice, forced micturition, and diuretics are not standard treatments for chronic pyelonephritis.

Which of the following statements about the use of angiotensin-converting enzyme inhibitor medications and autosomal recessive polycystic kidney disease (ARPKD) is accurate? A. The use of ACE inhibitors will increase the vasopressin levels. B. ACE inhibitors may interrupt the renin-angiotensin-aldosterone system to reduce renal vasoconstriction. C. The ACE inhibitors have been shown to shrink the size of the cysts inside the kidneys. D. ACE inhibitors should be used strictly in those clients who also have an underlying cardiac history.

B 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.

Which of the following client clinical manifestations most clearly suggests a need for diagnostic testing to rule out renal cell carcinoma? A. Urinary urgency B. Hematuria C. Oliguria D. Cloudy urine

B 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.

Prior to undergoing diagnostic testing with contrast, it is recommended that older adult clients have their creatinine level checked. The rationale for this is to ensure the client: A. Is not allergic to shell fish or iodine B. Will not undergo an acute kidney injury by decreasing renal blood flow C. Does not have a kidney stone obstructing the urethra D. Is in good enough health to withstand a walking on a treadmill

B Some drugs, such as diuretics, high molecular weight radiocontrast media, the immunosuppressive drugs cyclosporine and tacrolimus, and the nonsteroidal anti-inflammatory drugs (NSAIDs), can cause acute kidney injury by decreasing renal blood flow. Checking creatinine levels do not predict the client's allergies, a kidney stone, or tolerance for stress testing.

Which of the following assessment findings would lead the nurse to suspect the client has nephrotic syndrome? A. Hematuria and anemia B. Proteinuria and generalized edema C. Renal colic and increased serum sodium D. Increased creatinine with normal blood urea nitrogen

B The nephrotic syndrome is characterized by massive proteinuria and lipiduria, along with an associated hypoalbuminemia, generalized edema, and hyperlipidemia.

A 43-year-old female has recently been diagnosed with systemic lupus erythematosus (SLE) glomerulonephritis. She has presented to the out-client department to have a renal biopsy. Knowing the usual treatment options, the nurse should anticipate educating the client (who has a positive biopsy result) on which of the following medications being prescribed? Select all that apply. A. Lasix, a diuretic B. Prednisone, a corticosteroid C. Captopril, an ACE inhibitor D. Ampicillin, an antibiotic

B, C Treatment depends on the extent of glomerular involvement. Oral corticosteroids and angiotensin-converting enzyme (ACE) inhibitors are the mainstays of treatment. Diuretics and antibiotics are not part of the treatment protocol.

The physician suspects that a client with kidney stones has developed magnesium ammonium phosphate (struvite) stones based on which of the following urinalysis results? Select all that apply. A. Elevated uric acid levels B. Alkaline urine pH C. High urine phosphate level D. High bacterial count E. Presence of cystine particles

B, C, D Magnesium ammonium phosphate stones, also called struvite stones, form only in alkaline urine and in the presence of bacteria that possess an enzyme called urease, which splits the urea in the urine into ammonia and carbon dioxide. The ammonia that is formed takes up a hydrogen ion to become an ammonium ion, increasing the pH of the urine so that it becomes more alkaline. Because phosphate levels are increased in alkaline urine and because magnesium always is present in the urine, struvite stones form. Uric acid stones develop in conditions of gout and high concentrations of uric acid in the urine. Cystine stones account for less than 1% of kidney stones overall but represent a significant proportion of childhood calculi. They are seen in cystinuria, which results from a genetic defect in renal transport of cystine.

While taking a client history, which of the following assessments lead the nurse to suspect the client may have polycystic kidney disease? Select all that apply. A. Massive proteinuria on dipstick urine specimen B. Renal colic with flank pain C. Bright red blood in urine sample D. Elevated blood pressure of 180/94 E. Shortness of breath (SOB) with loud rhonchi and wheezes heard on auscultation

B, c, d The manifestations of ADPKD include pain from the enlarging cysts that may reach debilitating levels, episodes of gross hematuria from bleeding into a cyst, infected cysts from ascending UTIs, and hypertension resulting from compression of intrarenal blood vessels with activation of the renin-angiotensin mechanism. Renal colic caused by nephrolithiasis, or kidney stones, occurs in about 20% of persons with ADPKD. One type of pain associated with kidney stones is renal colic, described as colicky pain that accompanies stretching of the collecting system or ureter. Nephrotic syndrome is characterized by massive proteinuria. SOB with abnormal respiratory sounds is not usually associated with ADPKD.

An adult client has been diagnosed with polycystic kidney disease. Which of the client's following statements demonstrates an accurate understanding of this diagnosis? A. "I suppose I really should have paid more attention to my blood pressure." B. "I've always been prone to getting UTIs, and now I know why." C. "I suppose I should be tested to see if my children might inherit this." D. "I had a feeling that I was taking too many medications, and now I know the damage they can do."

C Autosomal dominant polycystic kidney disease is the most common of all inherited kidney diseases. The disorder is characterized by multiple expanding cysts of both kidneys that ultimately destroy the surrounding kidney structures and cause renal failure. The etiology of polycystic kidney disease (PKD) is not infective, and it is not caused by nephrotoxic drugs or uncontrolled hypertension.

A child is recovering from a bout with group A β-hemolytic Streptococcus infection. They return to the clinic a week later complaining of decrease in urine output with puffiness and edema noted in the face and hands. The health care provider suspects the child has developed: A. Autosomal recessive polycystic kidney disease B. Adult-onset medullary cystic disease C. Acute postinfectious glomerulonephritis D. Acute nephritic syndrome

C The classic case of poststreptococcal glomerulonephritis follows a streptococcal infection by approximately 7 to 12 days—the time needed for the development of antibodies. Oliguria, which develops as the GFR decreases, is one of the first symptoms. Proteinuria and hematuria follow because of increased glomerular capillary wall permeability. Sodium and water retention gives rise to edema (particularly of the face and hands) and hypertension. Adults with medullary cystic kidney disease present first with polyuria, polydipsia, and enuresis (bed-wetting), which reflect impaired ability of the kidneys to concentrate urine. 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. Acute nephritic syndrome is characterized by sudden onset of hematuria, variable degrees of proteinuria, diminished glomerular filtration rate (GFR), oliguria, and signs of impaired renal function.

An elderly female client has been hospitalized for the treatment of acute pyelonephritis. Which of the following characteristics of the client is most likely implicated in the etiology of her current health problem? The client: A. Has been diagnosed with type 2 diabetes several years earlier B. Takes a diuretic and an ACE inhibitor each day for the treatment of hypertension C. Recently had a urinary tract infection D. Has peripheral vascular disease

C There are two routes by which bacteria can gain access to the kidney: ascending infection from the lower urinary tract and through the bloodstream. Ascending infection from the lower urinary tract is the most important and common route by which bacteria reach the kidney, resulting in acute pyelonephritis. Diabetes, hypertension controlled by a diuretic and an ACE inhibitor, and peripheral vascular disease are not associated with acute pyelonephritis.

Glomerulonephritis is usually caused by: A. Vesicoureteral reflux B. Catheter-induced infection C. Antigen-antibody complexes D. Glomerular membrane viruses

C Two types of immune mechanisms have been implicated in the development of glomerular disease: injury resulting from antibodies reacting with fixed glomerular antigens and injury resulting from circulating antigen-antibody complexes that become trapped in the glomerular membrane. Reflux, which is the most common cause of chronic pyelonephritis, results from superimposition of infection on congenital vesicoureteral reflux or intrarenal reflux. Urinary catheters provide a means for microorganisms to ascend into the urinary tract to cause bladder infections or pyelonephritis.

An obese, male client with a history of gout and a sedentary lifestyle has been advised by his primary care provider to avoid organ meats, certain fish, and other foods that are high in purines. The care provider is demonstrating an awareness of the client's susceptibility to which of the following types of kidney stones? A. Calcium stones B Magnesium ammonium phosphate stones C. Uric acid stones D. Cystine stones

C Uric acid stones develop in conditions of gout and when high concentrations of uric acid in the urine. Unlike radiopaque calcium stones, uric acid stones are not visible on x-ray films. According to Table 25-2, these stones develop in clients who eat a high-purine diet like Atkins.

An infant has been diagnosed with autosomal recessive polycystic kidney disease (ARPKD). Which of the following treatment goals would be considered the priority in the care of this child? A. Rehydration therapy B. Total parenteral nutrition C. Prophylactic antibiotics D. Respiratory support

D Aggressive ventilatory support is often necessary for neonates with ARPKD, due to the presence of pulmonary hypoplasia and hypoventilation. Hydration, nutrition, and infection prevention are relevant aspects of care, but respiratory interventions are the priority.

A client has been given the diagnosis of diffuse glomerulonephritis. They ask the nurse what diffuse means. The nurse responds: A. Only some of the glomeruli are affected. B. Only one segment of each glomerulus is involved. C. That the mesangial cells are being affected. D. All glomeruli and all parts of the glomeruli are involved.

D Glomerular changes can be diffuse, involving all glomeruli and all parts of the glomeruli; focal, meaning only some of the glomeruli are affected; segmental, involving only a certain segment of each glomerulus; and mesangial, affecting only mesangial cells.

A young child has been diagnosed with Wilms tumor after his mother discovered an unusual mass, prompting a diagnostic workup. Which of the following characteristics is typical of Wilms tumor? The tumor is usually: A. Asymptomatic B. Self-limiting C. A secondary neoplasm D. Encapsulated

D Wilms tumor usually is a solitary mass that occurs in any part of the kidney. It usually is sharply demarcated and variably encapsulated. It is not a self-limiting health problem, and chemotherapy, radiotherapy, and/or surgery may be utilized. Symptoms include hypertension, abdominal pain, and vomiting.

mesangial cell function

remove proteins and debris, to keep filter clear

Decreased plasma colloidal osmotic pressure results in:

Shift of fluids from intra to extravascular spaces. Albuminemia means there is more protein outside the vessel than inside. Water moves from intravascular space into the extravascular space, causing edema.