Chapter 43: Urinary Elimination/Genitourinary Disorder

The nurse is reinforcing teaching with the caregiver of 5-year-old twins regarding urinary tract infections (UTIs). The caregiver is puzzled about why her daughter has had three urinary tract infections but her son has had none. She reports that their diets and fluid intake is similar. Which statement would be accurate for the nurse to tell this mother?

"A girl's urethra is much shorter and straighter than a boy's, so it can be contaminated fairly easily." Rationale: Many different bacteria may infect the urinary tract, and intestinal bacteria, particularly Escherichia coli, account for about 80% of acute episodes. The female urethra is shorter and straighter than the male urethra, so it is more easily contaminated with feces.

The nurse is preparing a 7-year-old girl for discharge after treatment for nephrotic syndrome. Which instructions would the nurse include in the discharge teaching plan for the parents?

"Let's meet with the dietitian and plan some meals." Rationale: Consultation with a dietitian would be most helpful for meal planning because so many of children's favorite foods are high in sodium. Restricting sodium may not be necessary if the child is not edematous; in addition, the statement does not teach. Protein-rich snacks should be encouraged. The nurse needs to provide the parents with specific instructions, assistance, and resources in addition to simple written instructions.

A parent asks the nurse, "What is precocious puberty?" The nurse's response should be based on which statement?

"Precocious puberty is early sexual development." Rationale: Precocious puberty is the early sexual development or maturation of a girl or boy. It occurs most often in girls, not boys, and does not relate to a heavy menses.

The caregiver of a 1-year-old boy calls the nurse, upset that his wife has just told him that their son is being given a hormone. His wife says that the pediatrician called it human chorionic gonadotropic hormone but that is all she understood. The nurse most accurately clarifies the caregiver's question by making which statement regarding the son's treatment?

"The doctor is hoping that the hormone will cause your son's undropped testes to move into their proper place." Rationale: Shortly before or soon after birth, the male gonads (testes) descend from the abdominal cavity into their normal position in the scrotum. Occasionally one or both of the testes do not descend, which is a condition called cryptorchidism. The testes are usually normal in size; the cause for failure to descend is not clearly understood. A surgical procedure called orchiopexy is used to bring the testes down into the scrotum and anchor them there. Some physicians prefer to try medical treatment such as injections of human chorionic gonadotropic hormone before doing surgery. If this is unsuccessful in bringing down the testes, orchiopexy is performed. If both testes remain undescended, the male will be sterile. If the processes vaginalis does not close, fluid from the peritoneal cavity passes through, causing hydrocele. If the hydrocele remains by the end of the first year, corrective surgery is performed.

The health care provider has prescribed a 24-hour urine specimen on a 15-year-old client. Review the steps below and place them in the correct order. Use all options.

> Confirm the client's identity. > Provide education to the client about the prescribed diagnostic test. > Document the time of the client's next voiding time. > Begin the testing time period. > Collect urine in a chilled container. > End the test at the 24-hour mark. Rationale: A 24-hour urine collection may be prescribed to assess the level of protein or creatinine. Once the testing prescription has been confirmed, the nurse confirms the identity of the client. Next, the nurse provides client education, followed by instructing the client that the next urine voided will be discarded and the 24-hour time period will begin. The next voided urine will be collected in the chilled container. Each void is collected and stored until the conclusion of the 24-hour time period.

Which instructions should a nurse give to a client who has a history of urinary tract infections to prevent recurrence? Select all that apply.

> Wipe from front to back > Encourage fluids throughout the day > Finish all antibiotics prescribed Rationale: Teaching caregivers to wipe from front to back, encouraging fluids, and finishing all prescribed medications are vital principles in the prevention of recurring UTIs. The use of bubble bath is contraindicated because it can be a source of infection.

The nurse is reviewing the health history of a client suspected of having vesicoureteral reflux. What findings in the health history are consistent with this disorder? Select all that apply.

> hematuria > flank pain > urinary frequency > history of repeated urinary tract infections Rationale: Vesicoureteral reflux (VUR) is a condition in which urine from the bladder flows back up the ureters. Primary VUR results from a congenital abnormality at the vesicoureteral junction that results in incompetence of the valve. Secondary VUR is related to other structural or functional problems such as neurogenic bladder, bladder dysfunction, or bladder outlet obstruction. Symptoms consistent with this condition include dysuria, urinary frequency, hematuria, back or flank pain, and previous urinary tract infections. Pus in the urine is not associated with this condition.

The nurse is caring for a 6-year-old male child who was brought to the pediatrician's office by the parent for a fever for the past few days.

A change in urinary frequency requires further assessment. Painful urination (dysuria) is an abnormal finding requiring further assessment. Costovertebral pain requires further follow-up, because it may indicate a complicated urinary tract infection (UTI). A temperature of 101.2°F (38.4°C) is an abnormal finding requiring further assessment. The presence of leukocytes in urinalysis indicates urinary tract infection (UTI). An elevated white blood cell (WBC) count of 12 × 103/mm3 (12 × 109/l) indicates infection and requires follow-up. A heart rate 110 beats/min is within normal range (70 to 110 beats/min). A respiratory rate 22 breaths/min is within normal range (20 to 30 breaths/min). A blood pressure 88/48 mm Hg is within normal range (the systolic blood pressure normal range is 80 to 120 mm Hg).

The nurse is collecting data on a 6-year-old child admitted with acute glomerulonephritis. Which vital sign would the nurse anticipate with this child's diagnosis?

Blood pressure 136/84 Rationale: Hypertension appears in 60% to 70% of clients during the first 4 or 5 days with a diagnosis of acute glomerulonephritis. The pulse of 112 would be a little high for a child this age, but not a concern with this diagnosis. The other vital signs are within normal limits for a child of this age.

A child is being evaluated for renal and urinary tract disease. What would the nurse expect to be ordered to evaluate the child's glomerular filtration rate?

Creatinine clearance rate Rationale: The glomerular filtration rate is measured by creatinine clearance rate, or the amount of creatinine excreted in 24 hours as determined by a 24-hour urine sample along with a venous blood sample and compared with the urine findings. Urinalysis provides general information about kidney function. A kidneys, ureters, and bladder x-ray provides information about the size and contour of the kidneys. A computed tomography reveals the size and density of kidney structures and adequacy of urine flow.

A parent is asking how to help the child deal with the peer ridicule at school in regards to enuresis. What is the best response by the nurse?

Demonstrate love and acceptance at home. Rationale: Enuresis is the continued incontinence of urine past the age of toilet training. It is a source of shame and embarrassment. It affects the child's life emotionally, behaviorally, and socially. It causes the child to have low self-esteem. Demonstrating love and acceptance at home will help counteract the ridicule the child is getting at school. The child should not be punished for a behavior he or she cannot control. Demonstrating how to use the toilet and going to the bathroom to void are good subjects but they do not help a child who has no control of the enuresis. Testing may need to be done to see if there are anatomical reasons, and medications may be needed to correct the problem.

A nurse is performing postoperative care on a child with a ureteral stent. Which intervention will help manage bladder spasms?

Encourage high fluid intake. Rationale: Prevent bladder stimulation secondary to a full rectum by completing a preoperative bowel evacuation, encouraging a high fluid intake, promoting early ambulation postoperatively, and administering a stool softener or glycerin suppository postoperatively.

A school nurse is trying to prevent poststreptococcal glomerulonephritis in children. What would be the best way to prevent this?

Encourage the child to take all the antibiotics if diagnosed with strep throat. Rationale: Encouraging the child to take all the antibiotics if diagnosed with strep throat is important. It is not necessary to test the people in the community with whom the child came in contact unless they are symptomatic. Ibuprofen does not cure strep throat, and strep infection is what usually causes poststreptococcal glomerulonephritis. Prophylactic antibiotics after a strep infection are not necessary.

A nurse is developing a teaching plan for the parents of an 8-year-old experiencing nocturnal enuresis. The nurse determines that additional teaching is needed when the parents identify what as an appropriate measure?

Encouraging fluid intake after dinner Rationale: In many children, limiting fluids after dinner can be helpful for nocturnal enuresis. Bladder-stretching exercises also can be helpful. If these measures are ineffective, desmopressin may be prescribed. Stress factors may be contributing to the child's problem. Therefore, measures to address stress and promote coping would be appropriate.

The nurse is educating the parents of a child requiring renal replacement therapy The parents express concern because they live in a remote, rural area with no access to pediatric specialty dialysis units. Which would the nurse recommend to the parents?

Peritoneal dialysis Rationale: Peritoneal dialysis is performed in the home setting after proper training. Hemodialysis is completed several times a week at a dialysis center. Renal transplant would be a discussion if the child needed a kidney transplant.

The nurse is caring for a 6-year-old child with acute glomerulonephritis. When reviewing the client's laboratory results, which result is most important to review with the health care provider?

Positive culture for group A streptococcus Rationale: Acute glomerulonephritis may result as an autoimmune response to the invasion of group A streptococcus. This group of streptococci affect the glomeruli of the kidneys. This would be addressed by the health care provider and is the most important of the laboratory results presented. If there is an active strep infection, it would need to be treated with an antibiotic. The white blood cell count is within normal limits. It is good to be negative for respiratory syncytial virus. The urine culture would have to be redone due to contamination. It does not provide an accurate status of the child's urine.

A 3-month-old boy is found to have undescended testes. The parents are concerned. What should the nurse anticipate as the next step for this client?

Reassess the client's testes at 6 months of age. Rationale: Because the testes sometimes descend spontaneously during the first year of life, treatment is usually delayed until at least 6 months of age. If testes have not descended between 6 and 12 months of age, the client may be given a short course of chorionic gonadotropin hormone to see if testicular descent can be stimulated. If this is not successful, surgical intervention (orchiopexy) will be needed to correct the condition to prevent infertility. Karyotyping is not needed in this situation, because the client's gender is already established.

The parent of 6-month-old girl is concerned about the child getting a urinary tract infection. What should the nurse mention to the parent regarding this concern?

Report any abnormally colored urine to the child's primary care provider. Rationale: Several important interventions can help prevent urinary and renal disease in children. The first intervention is to educate parents and caregivers about wiping from front to back (not back to front) when changing diapers of female infants. Remind parents of simple ways to prevent UTI, such as not allowing children to bathe with bubble bath. Teach parents to recognize that abnormally colored urine (red, black, or cloudy) should not be dismissed as this could be the beginning of a UTI or kidney disease. Educating parents about the importance of giving the full course of antibiotics prescribed for UTIs can help prevent return reinfection; giving the full course of antibiotics after a streptococcal infection can help prevent acute glomerulonephritis.

When providing care to a child with vesicoureteral reflux (VUR), which nursing diagnosis would be the priority?

Risk for infection Rationale: When vesicoureteral reflux is present, the primary goal is to avoid urine infection so that infected urine cannot gain access to the kidneys. Fluid volume typically is not a problem associated with VUR. Nutritional problems are not associated with VUR. Activity intolerance is not associated with VUR.

Which nursing diagnosis would be the priority when caring for a child in renal failure following a kidney transplant?

Risk for infection related to immunocompromised state Rationale: Children are administered immunosuppressants following a transplant. These drugs lower the immune system response and help prevent rejection following the transplant. As a result, this leaves them susceptible to infection. The child may have pain from the surgical procedure but it does not occur from the rejection of the organ. Constipation may occur from the opioids used for pain management but it is not the priority nursing diagnosis. The fluid volume should return to normal once the transplanted kidney is functioning properly.

The nurse is caring for a 10-year-old boy with end-stage kidney disease (ESKD) with metabolic acidosis. What would the nurse expect to administer if ordered?

Sodium bicarbonate tablets Rationale: Bicitra or sodium bicarbonate tablets are used for the correction of acidosis. Ferrous sulfate is used for the treatment of anemia. Vitamin D and calcium are used for the correction of hypocalcemia and hyperphosphatemia. Erythropoietin stimulates red blood cell growth.

The nurse is taking a health history of a 12-year-old boy presenting with scrotal pain. Which assessment finding would indicate testicular torsion?

Sudden onset of severe scrotal pain with significant hemorrhagic swelling Rationale: Testicular torsion is characterized by a testicle that is abnormally attached to the scrotum and twisted. Signs and symptoms include sudden onset of severe scrotal pain with significant hemorrhagic swelling. Enlarged glands and fever point to infection. A hardened and tender epididymis points to epididymitis. Fever and urethral discharge suggest infection. Scrotal swelling is associated with testicular torsion, epididymitis, and hydrocele.

The caregiver of a child being treated at home for acute glomerulonephritis calls the nurse reporting that her daughter has just had a convulsion. The child is resting comfortably but the caregiver would like to know what to do. The nurse would instruct the caregiver to take which action?

Take the child's blood pressure and report the findings to the nurse while the nurse is still on the phone. Rationale: Blood pressure should be monitored regularly using the same arm and a properly fitting cuff. If hypertension develops, a diuretic may help reduce the blood pressure to normal levels. An antihypertensive drug may be added if the diastolic pressure is 90 mm Hg or higher. The concern is immediate so reporting the findings in a few hours could delay needed treatment. The child should be weighed daily in the same clothes and using the same scale, but the blood pressure is the priority in this situation.

To prevent further urinary tract infections in a preschooler, what measures would you teach her mother?

Teach her to wipe her perineum front to back after voiding. Rationale: Escherichia coli can be easily spread from the rectum to the urinary meatus and cause infection if girls do not take precautions against this.

The nurse is caring for a 5-month-old boy with an undescended left testis. What would the nurse identify as indicative of true cryptorchidism?

Testis cannot be "milked" down inguinal canal Rationale: With true cryptorchidism, the retractile testis cannot be "milked" down the inguinal canal. Fluid in the scrotal sac is a hydrocele. A venous varicosity along the spermatic cord is a varicocele. Testis that can be brought into the scrotum refers to a retractile testis.

The nurse knows that which statement is a description of peritoneal dialysis when compared to hemodialysis:

The child can live a more normal lifestyle. Rationale: The child can live a more normal lifestyle with peritoneal dialysis. This is a 7-day-a-week procedure, but there are less diet restrictions and more freedom with this type of procedure. Peritoneal dialysis can be performed at home.

A pediatric client is scheduled for an intravenous pyelogram (IVP) of the kidney this afternoon. Which situation would require immediate attention by the nurse?

The child does not have intravenous access. Rationale: An intravenous pyelogram is an X-ray study of the upper urinary tract in which a radio opaque dye is injected into a peripheral vein, requiring intravenous access. The other choices are not a priority for this client.

A caregiver brings her 7-year-old son to the pediatrician's office, concerned about the child's bedwetting after being completely toilet trained even at night for over 2 years. The caregiver further reports that the child has wet the bed every night since returning home from a 1-week fishing trip. The child refuses to talk about the bedwetting. The nurse notes the child is shy, skittish, and will not make eye contact. Further evaluation needs to be done to rule out what possible explanation for the bedwetting?

The child has been sexually abused, maybe on the fishing trip. Rationale: Enuresis may have a physiologic or psychological cause and may indicate a need for further exploration and treatment. Enuresis in the older child may be an expression of resentment toward family caregivers or of a desire to regress to an earlier level of development to receive more care and attention. Emotional stress can be a precipitating factor. The health care team also needs to consider the possibility that enuresis can be a symptom of sexual abuse. Bruising, bleeding, or lacerations on the external genitalia, especially in the child who is extremely shy and frightened, may be a sign of child abuse (child mistreatment) and should be further explored.

The nurse is collecting data for a child diagnosed with acute glomerulonephritis. What would the nurse likely find in this child's history?

The child recently had an ear infection. Rationale: In the child with acute glomerulonephritis, presenting symptoms appear 1 to 3 weeks after the onset of a streptococcal infection, such as strep throat, otitis media, tonsillitis, or impetigo. There is not a family history of the disorder, a history of congenital concerns or defects, nor asthma in children with acute glomerulonephritis.

Which goal of therapy would be appropriate for a nurse to establish with a client's family and a client who has a diagnosis of enuresis?

The client remains continent throughout the night. Rationale: The goal of therapy is for the client to be continent of urine throughout the night. The nurse should encourage the child to awaken and void and not have any fluids before bedtime. During an activity, the child should be encouraged to void before and after the activity to prevent incontinence.

A newborn is diagnosed with hypospadias and the parents want the newborn to be circumcised. What would be the best response by the nurse?

The foreskin is needed for repair. Rationale: Hypospadias occurs when the meatal opening is on the ventral surface of the penis rather than at the end of the penis. The newborn with this condition is not circumcised at birth because the excess skin may be needed to reconstruct the meatus during surgical repair. Once the hypospadias is repaired, a circumcision can be performed as part of the procedure. Hypospadias repair is usually done after the newborn is 1 year or older. Meatal stenosis has to do with the urethral opening diameter, not the placement. Circumcision or hypospadias repair does not affect the functioning of the renal system so neither would predispose the newborn to renal failure.

A 15-year-old female adolescent visits the school nurse. The client appears anxious and states they have been dating a couple of different friends. The client states that they went to a party the other night and does not remember the entire night. The client states "I woke up and some of my clothes were missing. Now I have been experiencing some pain when I pee and there is yellow, green drainage that smells awful."

The nurse suspects the client has a sexually transmitted infection as evidenced by yellow, green odorous drainage Rationale: The symptoms the client is experiencing—yellow, green odorous discharge and painful urination—are consistent with trichomoniasis, a sexually transmitted infection (STI). Yellow, green odorous vaginal drainage indicates an STI. Yellow, green odorous vaginal drainage is indicative of a STI; it is not a sign or symptom of a urinary tract infection (UTI) or cervical cancer. The client did not state having sexual relations with the friends they were dating. Dysuria is a common sign of UTI and may occur in some STIs; however, green, yellow drainage is not consistent with a UTI. Yellow, green odorous vaginal drainage is a sign and symptom of an STI.

A nurse is discussing with a family the various causes of their child's vulvovaginitis. What would be included in the education?

The use of cleansing towelettes may have caused the vulvovaginitis. Rationale: Vulvovaginitis can result from an overgrowth of bacteria or yeast or from chemical factors. Chemical factors include bubble baths, and soaps or perfumes in personal care items like cleansing towelettes. This is a common childhood problem in girls. It is not necessarily a sign of abuse so child protective services would not need to be involved. Constipation and fevers are usually associated with this disorder but are not the cause.

A parent asks if her newborn's undescended testicles will need surgery to repair. What is the best response by the nurse?

There is a chance the testicles will descend on their own. Rationale: The Association of American Physicians recommends surgery at 1 year of age if the testicles have not descended on their own. There is a chance they may descend on their own prior to 1 year of age. This problem does not cause pain or swelling.

The nurse is reviewing the causative organisms noted on laboratory reports. Which organism is transmitted solely by sexual contact?

Trichomonas Rationale: The organism transmitted solely by sexual contact is Trichomonas. The other organisms are causes of various infections and acquired in various ways.

The nurse is caring for a child who is undergoing peritoneal dialysis. Immediately after draining the dialysate, which action should the nurse should take immediately?

Weigh the old dialysate. Rationale: The nurse should weigh the old dialysate to determine the amount of fluid removed from the child. The fluid must be weighed prior to emptying it. The nurse should weigh the new fluid prior to starting the next fill phase. Typically, the exchanges are 3 to 6 hours apart so the nurse would not immediately start the next fill phase.

A nurse is caring for a 13-year-old boy with end-stage kidney disease who is preparing to have his hemodialysis treatment in the dialysis unit. Which nursing action is appropriate?

Withhold his routine medication until after dialysis is completed. Rationale: The nurse should withhold routine medications on the morning that hemodialysis is scheduled since they would be filtered out through the dialysis process. His medications should be administered after he returns from the dialysis unit. A Tenckhoff catheter is used for peritoneal dialysis, not hemodialysis. The nurse should avoid blood pressure measurement in the extremity with the AV fistula as it may cause occlusion.

The nurse is caring for a child who receives dialysis via an AV fistula. Which finding indicates an immediate need to notify the physician?

absence of a thrill Rationale: The nurse should always auscultate the site for presence of a bruit and palpate for presence of a thrill. The nurse should immediately notify the physician if there is an absence of a thrill. Dialysate without fibrin or cloudiness is normal and is used with peritoneal dialysis, not hemodialysis.

The caregiver of a child with a history of ear infections calls the nurse and reports that her son has just told her his urine "looks funny." He also has a headache, and his mother reports that his eyes are puffy. Although he had a fever 2 days ago, his temperature is now down to 100℉ (37.8℃). The nurse encourages the mother to have the child seen by the care provider because the nurse suspects the child may have:

acute glomerulonephritis. Rationale: Acute glomerulonephritis is a condition that appears to be an allergic reaction to specific infections, most often group A beta-hemolytic streptococcal infections such as rheumatic fever. Presenting symptoms appear 1 to 3 weeks after the onset of a streptococcal infection such as strep throat, otitis media, tonsillitis, or impetigo. Usually the presenting symptom is grossly bloody urine. Periorbital edema may accompany or precede hematuria. Fever may be 103℉ to 104℉ (39.4℃ to 40℃) at the onset, but decreases in a few days to about 100℉ (37.8℃). Slight headache and malaise are usual, and vomiting may occur.

The nurse is caring for a child diagnosed with hydronephrosis. Which manifestation is consistent with complications of the disorder?

hypertension Rationale: Complications of hydronephrosis include renal insufficiency, hypertension, and eventually renal failure. Hypotension, hypothermia, and tachycardia are not associated with hydronephrosis.

Most urinary tract infections seen in children are caused by:

intestinal bacteria Rationale: Although many different bacteria may infect the urinary tract, intestinal bacteria, particularly Escherichia coli, account for about 80% of acute episodes. Hereditary and dietary concerns are not causes of urinary tract infections.

The nurse is concerned about the pediatric client's immune system after taking corticosteroids. Which laboratory study is the nurse most correct to assess?

leukocyte count Rationale: Since the nurse is concerned about the client's immune system, it is most correct to assess the client's white blood cells or cells of the immune system called leukocytes. Red blood cells are in a complete blood count, and low red blood cells result in anemia. Eosinophils and basophils are components of the white blood cells. They can indicate allergies.

Which clinical manifestation should a nurse recognize as most significant when assessing a client who is suspected of having female circumcision?

missing clitoris Rationale: Clients who are assessed with a missing clitoris should receive further workup for female circumcision. Redness, swelling, and vaginal discharge can be indicated for infection. Menses is not affected in clients with female circumcision.

A nurse should recognize that which symptom would be most consistent with a diagnosis of candidiasis?

thick, white discharge Rationale: A thick, white vaginal discharge is consistent with the findings of a client with suspected candidiasis. Bloody, brown, or absence of vaginal discharge is not typical of this condition.

A nurse has just admitted a client with symptoms of vulva inflammation, pain, odor, and pruritus. Based on these findings, the nurse could conclude that this client will be diagnosed with which condition?

vulvovaginitis Rationale: Vulvovaginitis is diagnosed with clients experiencing vaginal or vulval inflammation, pain odor, and pruritus. Pelvic inflammatory disease and urinary tract infection are not consistent with these symptoms.

A child is hospitalized with nephrotic syndrome. Which measurement is best for the nurse to determine the child's edema?

weight, daily Rationale: The classic sign of nephrotic syndrome is edema. It is usually generalized, but may be manifested as ascites or be periorbital depending on the seriousness of the disease. The easiest way to determine edema is by weighing the child. The child should be weighed on the same scale, at the same time daily, and with the same amount of clothing. The abdomen would only need to be measured if ascites was suspected or known. Measuring urine output will not determine edema, although it should be done to determine if urine is being produced in adequate amounts. Measuring the amount of protein in the urine will also not determine edema. The measurement is important to determine the progress of the disease, however.