Sherpath: Renal conditions

What is the correct series of events for the progression from acute to end stage renal disease?

1. Patient has edema, is hypertensive & hyperkalemic, and GFR is estimated at 50%. Optimistic regarding the ability to regain renal function. 2. Patient is not responding to treatments for hyperkalemia, GFR is estimated at 50%. Dialysis included in treatment plan. 3. Patient has irreversible loss of kidney function. GFR is estimated to have fallen below 50% and patient has hypertension. 4. Patient develops osteodystrophy (rickets) and anemia. The patient has rising serum creatinine & BUN levels and hypertension. 5. Patient has a GFR of less than 10%. Dialysis is continued. Kidney transplant is indicated

Which combined clinical evidence should best warrant dialysis in the AKI patient? Select all that apply. a. BUN >120 mg/dL b. Severe hypertension c. Estimated GFR of 95% d. Patient has fluid overload e. Pulmonary crackles that do not clear with a cough f. Blood pH is low and not responsive to intervention

a. BUN >120 mg/dL b. Severe hypertension d. Patient has fluid overload e. Pulmonary crackles that do not clear with a cough f. Blood pH is low and not responsive to intervention

A patient with glomerulonephritis is receiving intravenous fluids to regulate hydration but begins to experience pulmonary edema and worsening hypertension. Blood serum analysis shows hyperkalemia and increased BUN. The hyperkalemia does not respond to interventions. These clinical data should be an indication for the nurse to prepare for which steps in the management of acute renal failure? a. Dialysis b. Antibiotics c. Kidney transplant d. Update vaccinations

a. Dialysis In patients with acute renal failure, unresponsive hyperkalemia and increasing BUN, pulmonary edema and worsening hypertension are indications for dialysis.

Which statements help to clarify the main differences between peritoneal dialysis and hemodialysis? Select all that apply. a. Efficiency of dialysis b. Time required for dialysis c. Types of products removed d. Location of catheterization e. Caregiver involvement in dialysis treatment

a. Efficiency of dialysis Hemodialysis is more efficient than peritoneal dialysis. b. Time required for dialysis Hemodialysis requires less time than peritoneal dialysis. d. Location of catheterization Hemodialysis requires direct vascular access. Peritoneal dialysis requires catheterization of the abdomen. The risk for infection at access site in hemodialysis is higher. e. Caregiver involvement in dialysis treatment Peritoneal dialysis typically requires parents/caregivers to be actively involved in the dialysis treatment. Hemodialysis is performed in hospital or clinical settings.

Which patient scenarios should the nurse anticipate care for dialysis or kidney transplant? Select all that apply. a. Estimated GFR of ≤10%, hypertensive, anemic. b. Estimated GFR of 100% with hypertension and UTI. c. Severe hypertension and edema that are unresponsive to interventions. d. Resolving hyperkalemia, estimated GFR >50%, moderate hypertension. e. Severe edema and congestive heart failure. Hypertension and increasing BUN levels.

a. Estimated GFR of ≤10%, hypertensive, anemic. c. Severe hypertension and edema that are unresponsive to interventions. e. Severe edema and congestive heart failure. Hypertension and increasing BUN levels.

Which 3 factors need to be considered when planning care for a patient diagnosed with ESRD? Select all that apply. a. GFR b. Quality of life c. Blood pressure d. Hydration status e. Serum creatinine and BUN levels

a. GFR b. Quality of life e. Serum creatinine and BUN levels

Which set of clinical evidence will prompt a nurse to prepare for managing a patient with glomerulonephritis over nephrotic syndrome? Select all that apply. a. Hematuria b. Hypotensive c. Hypertensive d. Frothy urine e. Pallor & fatigue f. Abrupt onset edema

a. Hematuria Hematuria is a clinical manifestation of glomerulonephritis. c. Hypertensive Hypertension is a clinical manifestation of glomerulonephritis. f. Abrupt onset edema Abrupt onset edema, typically of the extremities and periorbital area, is a common clinical manifestation of glomerulonephritis.

Which manifestations should the nurse likely anticipate for a patient diagnosed with HUS? Select all that apply. a. Hematuria b. Hemolytic anemia c. Thrombocytopenia d. Stool culture that is positive for E. coli e. Stool culture that is positive for Staph aureus

a. Hematuria b. Hemolytic anemia c. Thrombocytopenia d. Stool culture that is positive for E. coli

Both nephrotic syndrome and glomerulonephritis have similar clinical manifestations. What evidence can be used to distinguish between the two disease states? Select all that apply. a. Hypertension b. Gross hematuria c. Glomerular dysfunction d. Normal serum albumin levels e. Normal serum electrolyte levels

a. Hypertension In glomerulonephritis the patient is hypertensive. In nephrotic syndrome the patient may be normo- or hypo-tensive. b. Gross hematuria Gross hematuria is evident in glomerulonephritis. Microscopic hematuria may be present in nephrotic syndrome. d. Normal serum albumin levels Normal serum albumin levels are found in glomerulonephritis. Hypoalbuminemia is a symptom of nephrotic syndrome. e. Normal serum electrolyte levels Normal serum electrolyte levels are seen in nephrotic syndrome. Altered electrolyte levels are found in glomerulonephritis.

Which explanation describes the rationale for immunizing children prior to receiving a kidney transplant? a. Immunosuppression that is required after transplant increases the risk for infections. b. After transplant, immunizations should be updated to provide specific protection for the new organ. c. The transplanted organ may harbor microbes, including viruses, to which the recipient was not previously exposed. d. Immunizations facilitate the systemic immunosuppression. Other immunosuppressive treatments only target functions of the kidney.

a. Immunosuppression that is required after transplant increases the risk for infections.

In which situation should peritoneal dialysis be favored over hemodialysis? a. Infants who are hemodynamically unstable b. Adolescents with chronic kidney disease (CKD) c. Infants with severe urinary tract infection (UTI) d. Adolescents with end-stage renal disease (ESRD)

a. Infants who are hemodynamically unstable

A common cause of HUS is the bacteria E.coli. Upon infection of the upper gastrointestinal tract, the bacteria secrete a toxin (Shiga toxin) which damages the endothelial walls of the capillaries and causes inflammation. How does this relate to renal function? a. Occlusion of the glomeruli by inflammation can decrease GFR. b. The toxins damage the lining of the ureters and prevent peristalsis into the bladder. c. Occlusion of the glomeruli increases glomerular pressure and increases GFR causing diuresis. d. Damage to the endothelium can result in proteinuria due to decreased size permeability and decreased GFR.

a. Occlusion of the glomeruli by inflammation can decrease GFR. Damage to the endothelium leads to inflammation that can occlude or decrease flow in the glomerulus. This leads to a decrease in GFR.

A patient presents with sudden onset of gross hematuria, proteinuria and hypertension. In assessing this patient, what statement best supports the importance for the nurse to assess the presence of throat discomfort over the past two weeks? a. Streptococcal pharyngitis can induce glomerulonephritis. b. Hemolytic uremic syndrome (HUS) initially presents with pharyngitis. c. Hematuria is the primary indicator that the patient has nephrotic syndrome caused by E. coli. d. Throat discomfort is an indication of edema which is the primary cause of nephrotic syndrome.

a. Streptococcal pharyngitis can induce glomerulonephritis. Acute poststreptococcal glomerulonephritis occurs as an immune reaction to a group A beta-hemolytic streptococcal infection of the throat or skin. Clinical symptoms usually develop 1-2 weeks after a streptococcal pharyngitis.

A 1-year-old child presents to the clinic with an abnormal abdominal bulge. The parents state the patient has been asymptomatic and the mass has not grown in size. The mass is also immobile. Upon close observation the child also has unusual appearing eyes. Why are both an ophthalmology and renal referral necessary in this patient? Select all that apply. a. The unusual appearing eyes, with missing or partial iris, are suggestive of Wilms tumor. b. Wilms tumor develops within the eye initially. It quickly metastasizes to the kidneys as blood is filtered. c. Renal referral is required because the large, immobile, abdominal mass in such a young child is indicative of Wilms tumor. d. The asymptomatic nature of the mass suggests it is a neuroblastoma. Neuroblastoma also affects the development of the eyes. e. During development, the kidneys and the eyes undergo significant differentiation during the same time. This typically results in anomalies in the kidneys and eyes simultaneously.

a. The unusual appearing eyes, with missing or partial iris, are suggestive of Wilms tumor. c. Renal referral is required because the large, immobile, abdominal mass in such a young child is indicative of Wilms tumor.

A family brings their toddler to the clinic because of frothy urine and a swollen face. Serum analysis confirms hypoalbuminemia and elevated hematocrit levels. The child is normotensive. Based on this clinical data, what care measure should the nurse anticipate in managing this patient? a. Hemodialysis to decrease edema b. Immunosuppression with corticosteroids c. Give normal saline IV to decrease hematocrit d. Decrease protein in diet to compensate for hypoalbuminemia

b. Immunosuppression with corticosteroids For the child with nephrotic syndrome, corticosteroids are continued until child is in remission—defined as <1+ urine protein for 3-7 consecutive days. Steroids are typically continued at the same daily dose for 4-6 weeks.

Which elements of a dietary regime are helpful in the therapeutic management of a child with CKD? Select all that apply. a. Include foods with sodium. b. Limit (regulate) fluid intake. c. Include foods the child enjoys. d. Allow the child to consume fluids freely. e. Individualize plan within restrictive parameters.

b. Limit (regulate) fluid intake. Regulating fluid intake will prevent exacerbation of edema and hypertension. c. Include foods the child enjoys. Including foods the child enjoys will be helpful for maintaining positive attitude in the child and may facilitate consumption of less favored foods. e. Individualize plan within restrictive parameters. Plans need to be individualized to ensure each child receives the nutrition needed without exacerbating symptoms of CKD.

An 8-year-old patient comes to the clinic with symptoms of acute kidney injury. While discussing recent events with the patient, the nurse learns that the patient attended a family barbeque the day before. Which statement explains the importance of this information? Select all that apply. a. Patient may have eaten pasteurized juice. b. The patient may have eaten improperly cooked meat. c. The patient may have consumed contaminated dairy products. d. Patient may have consumed too much water during the meal leading to water intoxication. e. The patient may have eaten mayonnaise products that were left unrefrigerated for too long.

b. The patient may have eaten improperly cooked meat. Undercooked meats, such as hamburger, may contain E.coli. Shiga toxin from the E.coli can cause gastrointestinal problems and HUS. c. The patient may have consumed contaminated dairy products. Unpasteurized dairy products may contain E.coli, which can cause HUS.

Which statement helps to explain why immunosuppressive therapy is needed for kidney transplantation? a. To increase endogenous cortisol production b. To prevent rejection of the transplanted organ c. To increase the protection generated by antibodies by decreasing the activity of macrophages d. To increase the number of antibodies produced against infectious agents but decrease the antibodies against "self"

b. To prevent rejection of the transplanted organ Even though the donor and recipient have compatible blood and tissue types, not all antigens are the same. Immunosuppression is necessary to prevent rejection caused by the antigenic activation of the immune system.

A patient has returned for a follow-up appointment for pharyngitis. The child now has altered electrolytes and an elevated ASO titer. The nurse notes facial edema and hypertension. Which finding confirms a diagnosis of acute poststreptococcal glomerulonephritis? a. Facial edema b. Hypertension c. Elevated ASO titer d. Altered electrolytes

c. Elevated ASO titer Elevated ASO titer provides evidence for acute poststreptococcal glomerulonephritis as it indicates a confirmation for strep infection.

Patient 1: Born with grade V VUR that is unresolved; has received conservative treatments to correct the reflux. Patient has developed a GFR of 10% over the past two months. Patient 2: Born with grade V VUR that is unresolved; has received conservative treatments to correct the reflux. Patient has a GFR of 50%. How should the nurse classify each patient based on the information provided? Select all that apply. a. Patient 1: Acute kidney injury b. Patient 1: Chronic kidney disease c. Patient 1: End-stage renal disease d. Patient 2: Acute kidney injury e. Patient 2: Chronic kidney disease f. Patient 2: End-stage renal disease

c. Patient 1: End-stage renal disease Patients with end-stage renal disease have irreversible kidney damage, as indicated by significant decrease in estimated GFR ≤10%. e. Patient 2: Chronic kidney disease Patients with chronic kidney disease have irreversible kidney damage, as indicated by estimated GFR 50%.

Why is it important to understand blood proteins in a patient with nephrotic syndrome? Select all that apply. a. Hyperalbuminemia develops as edema worsens. b. Proteins accumulate in the kidney preventing normal GFR. c. Proteins are filtered in the glomerulus and lost in the urine. d. Protein metabolism decreases due to negative feedback caused by hyperalbuminemia. e. Synthesis of liver proteins cannot keep up with need and patient develops hypoalbuminemia.

c. Proteins are filtered in the glomerulus and lost in the urine. Increased permeability in the glomerulus causes proteinuria in nephrotic syndrome. e. Synthesis of liver proteins cannot keep up with need and patient develops hypoalbuminemia. As proteins are lost in the urine, the liver works to maintain normal levels of blood proteins. Liver metabolism cannot synthesize proteins fast enough to compensate for loss.

What is the significance of thrombocytopenia in a patient with HUS? Select all that apply. a. Thrombocytopenia causes increased fluid loss and increased GFR. b. Thrombocytopenia causes anemia due to increased loss of RBCs in the urine. c. Thrombocytopenia potentiates small vessel occlusion and development of thrombi. d. Thrombocytopenia facilities a decrease in the hemoglobinuria that develops in HUS. e. Thrombocytopenia develops as platelets occlude vessels and then decreases blood flow and GFR.

c. Thrombocytopenia potentiates small vessel occlusion and development of thrombi. e. Thrombocytopenia develops as platelets occlude vessels and then decreases blood flow and GFR.

After eating hamburgers at the state fair, a patient develops bloody diarrhea. At the emergency department they are given IV antibiotics and fluids. During hospitalization, the nurse notes the patient is oliguric. Within a few days, the patient has copious amounts of dilute urine. Which is the most important complication for the nurse to assess for? a. Reactivation of HUS caused by dormant bacteria b. Edema caused by excessive loss of electrolytes in urine c. Dehydration caused by the inability to respond to antidiuretic hormone d. Dehydration and electrolyte imbalance due to slow nephron tubule recovery

d. Dehydration and electrolyte imbalance due to slow nephron tubule recovery

A renal parenchymal histological report of a 2-year-old patient confirms evidence of rare bilateral Wilms tumors affecting the kidneys. As the surgeon prepares for surgery, why is palpating or putting pressure on the abdomen avoided? a. Increased pressure on the tumor may cause a significant rise in blood pressure. b. Palpation or pressure near the tumor may cause it to shift and increase the difficulty of removal. c. Only with bilateral Wilms tumors will the surgeon use extra precautions to prevent the tumors from colliding. d. Increased pressure may cause the tumor to rupture and cancer cells may spread throughout the abdominal cavity.

d. Increased pressure may cause the tumor to rupture and cancer cells may spread throughout the abdominal cavity. Nurses often post signs to warn against palpation or pressure on the abdomen or tumor to prevent the rupture and spillage of tumor cells into the peritoneum. Family members should be aware of this precaution as well.