Patho Ch 34

a) Dorsiflexion of hands and feet Pg. 900 Neuromuscular Disorders Asterixis, which is involuntary dorsiflexion of hands and feet, can develop as CKD worsens. Burning sensation in feet, unsteady gait and demyelination of nerves can also accompany CKD, but are not part of asterixis.

6. A client with chronic kidney disease (CKD) has developed asterixis. The nurse knows that asterixis is: a) Dorsiflexion of hands and feet b) Demyelination of nerve fibers c) Unsteady gait d) Burning sensation in feet

d) Client with prostatic hyperplasia Pg. 893 Postrenal Acute Kidney Injury The most common cause of postrenal kidney failure is prostatic hyperplasia. Postrenal failure results from conditions that obstruct urine outflow. The obstruction can occur in the ureter, bladder, or urethra. Intratubular obstruction and acute pyelonephritis are intrarenal causes of kidney failure, and severe hypovolemia is a prerenal cause.

1. The nurse caring for four male clients recognizes which client is at highest risk for developing postrenal kidney failure? a) Client with severe hypovolemia b) Client with intratubular obstruction c) Client with acute pyelonephritis d) Client with prostatic hyperplasia

c) "The kidney is rich in blood supply and can concentrate toxins in high levels in the medullary portion of the kidney" Pg. 893 Acute Tubular Injury or Necrosis Alterations in pharmacokinetics occur with advancing age and increase the likelihood of toxic reactions. The kidney is rich in blood supply and can concentrate toxins in high levels in the medullary portion of the kidney. The toxic effects, which cause some minor necrosis, are generally limited to the proximal tubule. In addition, the kidney is an important site for metabolic processes that transform relatively harmless agents into toxic metabolites. It would not necessarily be effective care to rely on medication therapy as only a last resort. Monitoring would not prevent toxicity but rather identify it earlier. Not all medications can be prescribed by a client's weight.

10. With the increased risk of drug toxicity among chronically ill older adults, which statement by the nurse explains why the older adult's kidney is vulnerable to toxic injury? a) "The health care provider does not always monitor for toxicity at each follow-up appointment" b) "Prescribed medications may not be monitored as closely as they should be since Medicare does not reimburse for routine laboratory testing" c) "The kidney is rich in blood supply and can concentrate toxins in high levels in the medullary portion of the kidney" d) "Every drug dosage should be determined by client weight but most clients refuse to get on the scale"

c) A loss of over half the client's normal kidney function Pg. 895 Definition and Classification In clinical practice, GFR is usually estimated using the serum creatinine concentration. A GFR below 60 mL/minute/1.73 m2 represents a loss of one half or more of the level of normal adult kidney function. The GFR is not diagnostic for concentrated urine or the need to drink more water.

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

d) Serum creatinine Pg. 896 Assessment of Glomerular Filtration Rate and Other Indicators of Renal Function In clinical practice, GFR is usually estimated using the serum creatinine concentration. The other answers are not used to estimate the GFR.

9. The GFR is considered to be the best measure of renal function. What is used to estimate the GFR? a) BUN b) Albumin level c) Serum protein d) Serum creatinine

d) Blood work for hemoglobin, red blood cells, and hematocrit Pg. 897 Accumulation of Nitrogenous Wastes Anemia is a frequent and debilitating consequence of CKD. The anemia may be due to chronic blood loss, hemolysis, bone marrow suppression due to retained uremic factors, and decrease in red cell production due to impaired production of erythropoietin and iron deficiency. Pancreatic function is not typically affected by CKD, and endoscopic examination is less likely to reveal a cause of fatigue. An infectious etiology is possible and would be informed by white cell assessment, but this is less likely than anemia given the client's report of symptoms.

11. A client with a history of chronic kidney disease (CKD) is experiencing increasing fatigue, lethargy, and activity intolerance. The care team has established that the client's glomerular filtration rate (GFR) remains at a low, but stable, level. Which laboratory assessments will most likely be prescribed to help determine the cause of these new symptoms? a) Cystoscopy and ureteroscopy b) Blood work for white cells and differential c) Assessment of pancreatic exocrine and endocrine function d) Blood work for hemoglobin, red blood cells, and hematocrit

a) Increasing the normal saline intravenous infusion rate prior to the exam Pg. 892 Some drugs such as high-molecular-weight radiocontrast media, the immunosuppressive drugs cyclosporine and tacrolimus, and nonsteroidal anti-inflammatory drugs can cause acute prerenal failure by decreasing renal blood flow. Administering intravenous saline can improve hydration and renal perfusion to decrease the toxic effects of the radiocontrast media.

12. A client is to receive a radiocontrast media as part of a diagnostic scan. Which intervention is intended to reduce the nephrotoxic effects of the radiocontrast media? a) Increasing the normal saline intravenous infusion rate prior to the exam b) Administering ibuprofen 600 mg prior to the procedure c) Having the client take nothing by mouth d) Administering one unit of packed red blood cells

a) Diuretics Pg. 894 Diagnosis and Treatment Diuretics, which directly affect renal excretion of sodium, can alter the fractional excretion of sodium. The other drug types listed do not affect this parameter of renal function.

13. Several urine tests can be useful in establishing a diagnosis of acute renal failure (ARF). The nurse must consider that fractional excretion of sodium can be particularly affected by administration of which type of drug? a) Diuretics b) Beta-adrenergic blockers (beta-blockers) c) Sulfonylureas d) Calcium channel blockers

c) Anemia Pg. 899 Anemia The most common hematologic disorder that accompanies CKD is anemia.

14. Chronic kidney disease impacts many systems in the body. What is the most common hematologic disorder caused by CKD? a) Polycythemia b) Leukocytosis c) Anemia d) Erythrocythemia

b) Development of metabolic dysfunction d) Increased risk of developing cancer e) Cardiovascular complications Pg. 893 Acute Tubular Injury or Necrosis Most immunosuppressive drugs have serious side effects such as cardiovascular complications, metabolic dysfunction, and cancer. Rarely do these medications harm the newly transplanted kidney. Development of moon face and buffalo hump are classic signs and symptoms of Cushing syndrome and can be associated with steroids like prednisone. Ringing or buzzing in the ears can be associated with ibuprofen intake.

15. Following kidney transplantation, the client is prescribed maintenance immunosuppressive therapy consisting of prednisone, azathioprine, and cyclosporine. While educating the client about the immunosuppressive therapy, which side effects should the nurse include in the teaching plan? Select all that apply. a) Nephrotoxicity of newly transplanted kidney b) Development of metabolic dysfunction c) Ringing or buzzing in the ears d) Increased risk of developing cancer e) Cardiovascular complications

c) Creatinine Pg. 896 Assessment of Glomerular Filtration Rate and Other Indicators of Renal Function In clinical practice, GFR is usually estimated using the serum creatinine concentration. The presence of myoglobin or large amounts of protein in the urine is suggestive of renal failure. Serum blood urea nitrogen levels are clinically useful; however, GFR is not calculated from these values.

16. A client asks, "Why did my provider order a glomerular filtration rate (GFR) to my usual blood work?" The nurse's best response is based on the fact that GFR can estimate serum levels of which substance? a) Protein b) Myoglobin c) Creatinine d) Urea

b) Diabetes mellitus e) Hypertension Pg. 895 Chronic Kidney Disease Hypertension and diabetic kidney disease are the two main causes of CKD in Western societies. It is not autoimmune disease, substance use disorder, or alcohol use disorder.

17. When educating a group of nursing students about the primary causes of chronic kidney disease (CKD) in Western societies, the nurse asks, "What do you think are the main causes of CKD in adults?" Which student answer(s) is deemed correct? Select all that apply. a) Autoimmune diseases b) Diabetes mellitus c) Substance use disorder d) Alcohol use disorder e) Hypertension

a) Systemic disease b) Renal disease e) Nonrenal urological abnormalities Pg. 890 Acute Kidney Injury and Chronic Kidney Disease Underlying causes of renal failure include renal or systemic disease and nonrenal urologic abnormalities. Hepatic disease and malnutrition might gradually influence renal function (since they can influence many body functions), but are not considered direct causes of renal failure.

18. The nurse recognizes that renal failure may result from which underlying causes? Select all that apply a) Systemic disease b) Renal disease c) Hepatic disease d) Malnutrition e) Nonrenal urological abnormalities

a) 20 mg/dL (7.14 mmol/L) Pg. 897 Accumulation of Nitrogenous Wastes Normal levels of blood urea nitrogen are approximately 20 mg/dL or less. The level increases as CKD worsens and can go as high as 800 mg/dL (285.60 mmol/L).

19. Accumulation of nitrogenous wastes such as urea in the circulatory system is an early sigh of chronic kidney disease (CKD). The nurse knows that normal levels of urea in blood are approximately: a) 20 mg/dL (7.14 mmol/L) b) 100 mg/dL (35.70 mmol/L) c) 60 mg/dL (21.42 mmol/L) d) 80 mg/dL (28.56 mmol/L)

b) A client with a recent diagnosis of type 2 diabetes who does not monitor blood sugars or control diet Pg. 894 Diagnosis and Treatment Chronic kidney disease (CKD) is a pathophysiologic process that results in the loss of nephrons and a decline in renal function that has persisted for more than 3 months. CKD can result from diabetes, hypertension, glomerulonephritis, lupus (SLE), and polycystic kidney disease. The prevalence and incidence of CKD continue to grow, reflecting the growing elderly population and the increasing number of people with diabetes and hypertension. Hemorrhage may result in acute renal failure, but it is not associated with chronic kidney disease. Stroke and loss of the thyroid gland are not noted to underlie cases of chronic kidney disease.

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

c) Dietary protein Pg. 903 Protein Restriction of dietary proteins may decrease the progress of renal impairment in people with advanced renal disease. Proteins are broken down to form nitrogenous wastes, and reducing the amount of protein in the diet lowers the blood urea nitrogen and reduces symptoms.

20. The nurse is instructing a client with advanced kidney disease (AKD) about a dietary regimen. Which restriction should the nurse be sure to include in the treatment plan to decrease the progress of renal impairment in people with AKD? a) Carbohydrates b) Fats c) Dietary protein d) Foods high in calcium

c) Obstruction of the renal tubules with myoglobin and damaged tubular cells Pg. 893 Acute Tubular Injury or Necrosis Myoglobin normally is not found in the serum or urine. It has a low molecular weight; if it escapes into the circulation, it is rapidly filtered in the glomerulus. A life-threatening condition known as rhabdomyolysis occurs when increasing myoglobinuria levels cause myoglobin to precipitate in the renal tubules, leading to obstruction and damage to surrounding tubular cells. Myoglobinuria most commonly results from muscle trauma but may result from exertion, hyperthermia, sepsis, prolonged seizures, and alcoholism or drug abuse. Rhabdomyolysis is not cured with anticoagulation administration nor does it cause kidney stones. Compartment syndrome occurs when there is insufficient blood supply to muscles and nerves due to increased pressure within one of the body's compartments. Myoglobinuria causes hyperkalemia, which may cause cardiac dysrhythmias, metabolic acidosis, hyperphosphatemia, early hypocalcemia, and late hypercalcemia.

21. The client with substance use disorder was found unconscious after overdosing on heroin 2 days prior. Because of prolonged pressure on the muscles the client has developed myoglobinuria, causing which complication? a) Hypokalemia and metabolic acidosis b) Development of renal stones due to stasis c) Obstruction of the renal tubules with myoglobin and damaged tubular cells d) Compartment syndrome in the lower extremities

c) Prerenal Pg. 892 Prerenal Acute Kidney Injury Prerenal failure occurs when vascular volume and renal perfusion are decreased, for example by dehydration. Postrenal failure is the result of obstruction of urine outflow. Intrarenal (intrinsic) failure occurs when nephrons are destroyed.

22. An 86-year-old client is being treated for dehydration and hyponatremia after curtailing fluid intake to prevent urinary incontinence. Given these findings, the nurse recognizes that this client is likely in what phase of acute kidney injury? a) Intrarenal b) Intrinsic c) Prerenal d) Postrenal

b) Peritonitis Pg. 903 Peritoneal Dialysis Potential problems with peritoneal dialysis include infection, catheter malfunction, dehydration, hyperglycemia, and hernia. Bowel perforation can occur, but the fluid would be stool colored. The client may develop hyperglycemia; however, this will not cause the fluid to be cloudy. If bladder erosion had occurred, the fluid would look like urine and not be cloudy and white.

23. While assessing a peritoneal dialysis client in the home, the nurse notes that the fluid draining from the abdomen is cloudy, is white in color, and contains a strong odor. The nurse suspects this client has developed a serious complication known as: a) Too much sugar in the dialysis solution b) Peritonitis c) Bladder erosion d) Bowel perforation

b) Oliguric phase Pg. 893 Postrenal Acute Kidney Injury The oliguric phase of AKI is characterized by marked decrease in glomerular filtration rate (GFR), causing sudden retention of endogenous metabolites, such as urea, potassium, sulfate, and creatinine, that normally are cleared by the kidneys. The urine output is usually lowest at this point. Fluid retention gives rise to edema, water intoxication, and pulmonary congestion. AKI typically progresses through four phases: the onset phase, during which tubular injury is induced; the oliguric phase, during which the GFR falls, nitrogenous wastes accumulate, and urine output decreases; the diuretic phase when the kidneys try to heal and urine output increases; and the recovery phase, where tubular edema resolves and renal function improves. During recovery, there is normalization of fluid and electrolyte balance.

24. A client with postrenal acute kidney injury (AKI) exhibits oliguria and edema with laboratory results revealing increased levels of urea, potassium, and creatinine. Based on these data, which phase of AKI is this client most likely experiencing? a) Diuretic phase b) Oliguric phase c) Recovery phase d) Onset phase

a) Diuretic phase Pg. 893-894 Postrenal Acute Kidney Injury The onset phase lasts hours/days and is the time from the onset of the precipitating event until tubular injury occurs. The oliguric phase is characterized by a marked decrease in glomerular filtration rate, causing sudden retention of endogenous metabolites, such as urea, potassium, sulfate, and creatinine. The diuretic phase occurs when the kidneys try to heal and one will see an increase/excessive output (diuresis) of dilute urine. The recovery phase is the period during which tubular edema resolves and renal function improves. There is normalization of fluid and electrolyte balance.

25. A client is beginning to recover from acute tubular necrosis. During which phase of acute kidney injury will the nurse assess an increase in urine output? a) Diuretic phase b) Oliguric phase c) Recovery phase d) Onset phase

d) Antihypertensive medications Pg. 900 Hypertension Hypertension is a common result of CKD, and the mechanisms that produce hypertension in CKD include increased vascular volume, elevation of peripheral vascular resistance, decreased levels of renal vasodilator prostaglandins, and increased activity of the renin-angiotensin-aldosterone system. NSAIDs, opioids, and antiarrhythmics are not as frequently indicated for the treatment of CKD.

3. A client has been diagnosed with chronic kidney disease (CKD). Which drug category is usually administered to treat coexisting conditions that manifest early in CKD? a) Antiarrhythmic medications b) Nonsteroidal anti-inflammatory drugs (NSAIDs) c) Opioid analgesics d) Antihypertensive medications

b) Treatment involves the introduction into the peritoneum of a sterile dialyzing solution, which is drained after a specified time Pg. 902 Hemodialysis In peritoneal dialysis, a sterile dialyzing solution is instilled into the peritoneum through a catheter over approximately 10 minutes. The solution remains ("dwells") in the peritoneal cavity for a determined time interval, then drains into a sterile bag. Shunts, fistulas, and artificial dialyzers are associated with hemodialysis, which is usually performed three times weekly. The frequency of peritoneal dialysis varies, but is normally performed more often than hemodialysis and can be done at home.

4. A client with chronic kidney disease (CKD) will be managed with peritoneal dialysis. Which description of this type of dialysis is most accurate? a) Vascular access is achieved through an internal arteriovenous fistula or an external arteriovenous shunt b) Treatment involves the introduction into the peritoneum of a sterile dialyzing solution, which is drained after a specified time c) Treatments typically occur three times each week for 3 to 4 hours d) The dialyzer is usually a hollow cylinder composed of bundles of capillary tubes

a) Dry skin and pruritus Pg. 897 Accumulation of Nitrogenous Wastes Dry, itchy skin is a common consequence of CKD. Petechiae, purpura, hirsutism, psoriasis, alopecia, and fungal rashes are not noted to accompany or result from CKD.

5. Which dermatologic problem most often accompanies chronic kidney disease (CKD)? a) Dry skin and pruritus b) Petechiae and purpura c) Hirsutism and psoriasis d) Alopecia and fungal rashes

c) Baseline urine output of 50 mL/hr that is now 10 mL/hr Pg. 896 Assessment of Glomerular Filtration Rate and Other Indicators of Renal Function The kidney normally responds to a decrease in the glomerular filtration rate with a decrease in urine output. Thus, an early sign of prerenal failure is a sharp decrease in urine output.

7. The nurse is caring for a client who has had acute blood loss from ruptured esophageal varices. What does the nurse recognize is an early sign of prerenal failure? a) Baseline blood pressure of 150/90 mm Hg that is now 130/80 mm Hg b) Foul smelling, cloudy urine c) Baseline urine output of 50 mL/hr that is now 10 mL/hr d) Baseline heart rate of 100 bpm that has increased to 120 bpm