Renal- NCLEX Qs and Lecture Notes

Diabetes insipidus

"Sour urine," not related to blood sugar Lack ADH-- pee a lot Caused by kidney disease, brain trauma

Lupus

- Autoimmune disease that attacks small blood vessels (loves to attack kidneys) - primarily affects females (15-45 y/o) - Cause of death is usually kidney failure ("lupus nephritis")

Chronic pyelonephritis

- Persistent or recurring episodes of acute pyelonephritis that lead to scarring - Risk of chronic pyelonephritis increases in individuals with renal infections and some type of obstructive pathologic condition - Early symptoms: hypertension, frequency, dysuria, flank pain - Progression leads to kidney failure

Which drug is indicated for pain related to acute renal calculi? A. Narcotic analgesics B. Nonsteroidal anti-inflammatory drugs (NSAIDS) C. Muscle relaxants D. Salicylates

A. Narcotic analgesics are usually needed to relieve the severe pain of renal calculi. Muscle relaxants are typically used to treat skeletal muscle spasms. NSAIDS and salicylates are used for their anti-inflammatory and antipyretic properties and to treat less severe pain.

You have a paraplegic patient with renal calculi. Which factor contributes to the development of calculi? A. Increased calcium loss from the bones B. Decreased kidney function C. Decreased calcium intake D. High fluid intake

A. Bones lose calcium when a patient can no longer bear weight. The calcium lost from bones form calculi, a concentration of mineral salts also known as a stone, in the renal system.

What change indicates recovery in a patient with nephrotic syndrome? A. Disappearance of protein from the urine B. Decrease in blood pressure to normal C. Increase in serum lipid levels D. Gain in body weight

A. With nephrotic syndrome, the glomerular basement membrane of the kidney becomes more porous, leading to loss of protein in the urine. As the patient recovers, less protein is found in the urine.

Acute pyelonephritis

Acute infection of the renal pelvis interstitium (Vesicoureteral reflux, E. coli, Proteus, Pseudomonas)

Treatment of acute cystitis

Antimicrobial therapy (could get worse) Increased fluid intake (could get worse) Avoidance of bladder irritants Urinary analgesics

Your 60 y.o. patient with pyelonephritis and possible septicemia has had five UTIs over the past two years. She is fatigued from lack of sleep, has lost weight, and urinates frequently even in the night. Her labs show: sodium, 154 mEq/L; osmolarity 340 mOsm/L; glucose, 127 mg/dl; and potassium, 3.9 mEq/L. Which nursing diagnosis is priority? A. Fluid volume deficit related to osmotic diuresis induced by hyponatremia B. Fluid volume deficit related to inability to conserve water C. Altered nutrition: Less than body requirements related to hypermetabolic state D. Altered nutrition: Less than body requirements related to catabolic effects of insulin deficiency

B.

Which cause of hypertension is the most common in acute renal failure? A. Pulmonary edema B. Hypervolemia C. Hypovolemia D. Anemia

B. Acute renal failure causes hypervolemia as a result of overexpansion of extracellular fluid and plasma volume with the hypersecretion of renin. Therefore, hypervolemia causes hypertension.

Which of the following symptoms do you expect to see in a patient diagnosed with acute pyelonephritis? A. Jaundice and flank pain B. Costovertebral angle tenderness and chills C. Burning sensation on urination D. Polyuria and nocturia

B. Costovertebral angle tenderness, flank pain, and chills are symptoms of acute pyelonephritis. Jaundice indicates gallbladder or liver obstruction. A burning sensation on urination is a sign of lower urinary tract infection.

A 30 y.o. female patient is undergoing hemodialysis with an internal arteriovenous fistula in place. What do you do to prevent complications associated with this device? A. Insert I.V. lines above the fistula. B. Avoid taking blood pressures in the arm with the fistula C. Palpate pulses above the fistula D. Report a bruit or thrill over the fistula to the doctor

B. Don't take blood pressure readings in the arm with the fistula because the compression could damage the fistula. IV lines shouldn't be inserted in the arm used for hemodialysis. Palpate pulses below the fistula. Lack of bruit or thrill should be reported to the doctor.

What is the most important nursing diagnosis for a patient in end-stage renal disease? A. Risk for injury B. Fluid volume excess C. Altered nutrition: less than body requirements D. Activity intolerance

B. Kidneys are unable to rid the body of excess fluids which results in fluid volume excess during ESRD.

A patient with diabetes mellitus and renal failure begins hemodialysis. Which diet is best on days between dialysis treatments? A. Low-protein diet with unlimited amounts of water B. Low-protein diet with a prescribed amount of water C. No protein in the diet and use of a salt substitute D. No restrictions

B. The patient should follow a low-protein diet with a prescribed amount of water. The patient requires some protein to meet metabolic needs. Salt substitutes shouldn't be used without a doctor's order because it may contain potassium, which could make the patient hyperkalemic. Fluid and protein restrictions are needed.

What is the priority nursing diagnosis with your patient diagnosed with end-stage renal disease? A. Activity intolerance B. Fluid volume excess C. Knowledge deficit D. Pain

B. Fluid volume excess because the kidneys aren't removing fluid and wastes. The other diagnoses may apply, but they don't take priority.

The most common early sign of kidney disease is: A. Sodium retention B. Elevated BUN level C. Development of metabolic acidosis D. Inability to dilute or concentrate urine

B. Increased BUN is usually an early indicator of decreased renal function.

Which of the following causes the majority of UTI's in hospitalized patients? A. Lack of fluid intake B. Inadequate perineal care C. Invasive procedures D. Immunosuppression

C. Invasive procedures such as catheterization can introduce bacteria into the urinary tract. A lack of fluid intake could cause concentration of urine, but wouldn't necessarily cause infection.

A patient with diabetes has had many renal calculi over the past 20 years and now has chronic renal failure. Which substance must be reduced in this patient's diet? A. Carbohydrates B. Fats C. Protein D. Vitamin C

C. Because of damage to the nephrons, the kidney can't excrete all the metabolic wastes of protein, so this patient's protein intake must be restricted. A higher intake of carbs, fats, and vitamin supplements is needed to ensure the growth and maintenance of the patient's tissues.

Clinical manifestations of acute glomerulonephritis include which of the following? A. Chills and flank pain B. Oliguria and generalized edema C. Hematuria and proteinuria D. Dysuria and hypotension

C. Hematuria and proteinuria indicate acute glomerulonephritis. These finding result from increased permeability of the glomerular membrane due to the antigen-antibody reaction. Generalized edema is seen most often in nephrosis.

Which finding leads you to suspect acute glomerulonephritis in your 32 y.o. patient? A. Dysuria, frequency, and urgency B. Back pain, nausea, and vomiting C. Hypertension, oliguria, and fatigue D. Fever, chills, and right upper quadrant pain radiating to the back

C. Mild to moderate HTN may result from sodium or water retention and inappropriate renin release from the kidneys. Oliguria and fatigue also may be seen. Other signs are proteinuria and azotemia.

An 18 y.o. student is admitted with dark urine, fever, and flank pain and is diagnosed with acute glomerulonephritis. Which would most likely be in this student's health history? A. Renal calculi B. Renal trauma C. Recent sore throat D. Family history of acute glomerulonephritis

C. The most common form of acute glomerulonephritis is caused by group A beta-hemolytic streptococcal infection elsewhere in the body.

Which patient is at greatest risk for developing a urinary tract infection (UTI)? A. 35 y.o. woman with a fractured wrist B. 20 y.o. woman with asthma C. 50 y.o. postmenopausal woman D. 28 y.o. with angina

C. Women are more prone to UTI's after menopause due to reduced estrogen levels. Reduced estrogen levels lead to reduced levels of vaginal Lactobacilli bacteria, which protect against infection. Angina, asthma and fractures don't increase the risk of UTI.

Nephritic syndrome

Caused by increased permeability of the glomerular filtration membrane with pore sizes large enough to allow passage of RBCs and protein Findings: hematuria, oliguria, azotemia, hypertension

Which intervention do you plan to include with a patient who has renal calculi? A. Maintain bed rest B. Increase dietary purines C. Restrict fluids D. Strain all urine

D. All urine should be strained through gauze or a urine strainer to catch stones that are passed. The stones are then analyzed for composition. Ambulation may help the movement of the stone down the urinary tract. Encourage fluid to help flush the stones out.

A patient diagnosed with sepsis from a UTI is being discharged. What do you plan to include in her discharge teaching? A. Take cool baths B. Avoid tampon use C. Avoid sexual activity D. Drink 8 to 10 eight-oz glasses of water daily

D. Drinking 2-3L of water daily inhibits bacterial growth in the bladder and helps flush the bacteria from the bladder. The patient should be instructed to void after sexual activity.

Your patient has complaints of severe right-sided flank pain, nausea, vomiting and restlessness. He appears slightly pale and is diaphoretic. Vital signs are BP 140/90 mmHg, Pulse 118 beats/min., respirations 33 breaths/minute, and temperature, 98.0F. Which subjective data supports a diagnosis of renal calculi? A. Pain radiating to the right upper quadrant B. History of mild flu symptoms last week C. Dark-colored coffee-ground emesis D. Dark, scanty urine output

D. Patients with renal calculi commonly have blood in the urine caused by the stone's passage through the urinary tract. The urine appears dark, tests positive for blood, and is typically scant.

A 22 y.o. patient with diabetic nephropathy says, "I have two kidneys and I'm still young. If I stick to my insulin schedule, I don't have to worry about kidney damage, right?" Which of the following statements is the best response? A. "You have little to worry about as long as your kidneys keep making urine." B. "You should talk to your doctor because statistics show that you're being unrealistic." C. "You would be correct if your diabetes could be managed with insulin." D. "Even with insulin, kidney damage is still a concern."

D. Kidney damage is still a concern. Microvascular changes occur in both of the patient's kidneys as a complication of the diabetes. Diabetic nephropathy is the leading cause of end-stage renal disease. The kidneys continue to produce urine until the end stage. Nephropathy occurs even with insulin management.

Renal insufficiency

Decline in renal function to about 25% of normal or a GFR of 25-30 ml/min

Nephrotic syndrome

Excretion of 3.5 g or more of protein in the urine per day Findings: Massive proteinuria, hypoalbuminemia, edema, hyperlipidemia/hyperlipiduria

Manifestations of pyelonephritis

Fever, chills, flank or groin pain along with symptoms of UTI (hard to differentiate from cystitis- need urine culture/urinalysis)

Manifestations of acute cystitis

Frequency, dysuria, urgency, lower abdominal and/or suprapubic pain

Neurogenic bladder

General term for bladder dysfunction caused by neurologic disorders (i.e. stroke, TBI, MS, Alzheimer, Guillan-Barre)

Clinical manifestations of bladder tumors

Gross, painless hematuria Frequent daytime voiding, nocturia, urgency, urinary incontinence

Clinical manifestations of renal tumors

Hematuria, dull and aching flank pain, palpable flank mass, weight loss, metastasis to lung, lymph nodes, liver, bone, thyroid, CNS

2 Major Symptoms of Glomerulonephritis

Hematuria, proteinuria

Post-streptococcal glomerulonephritis

Immune mediated, after you get strep, the kidneys are attacked Classic presentation: young patient wakes up with facial edema, just had strep throat a few weeks ago Usually goes away on its own

Acute cystitis

Inflammation of the bladder, not necessarily an infection

Glomerulonephritis

Inflammation of the glomerulus caused by primary glomerular injury, including immunologic responses, ischemia, free radicals, drugs, toxins, vascular disorders, infection - Secondary glomerular injury is due to systemic diseases, including DM, systemic lupus erythematosus, CHF, HIV

Urinary Tract Infection

Inflammation of the urinary epithelium caused by bacteria (most common pathogen-->E. coli)

Urinary Tract Obstruction

Interference with the flow of urine at any site along the urinary tract.

Severity of urinary tract obstruction based on:

Location, completeness, involvement of one or both upper urinary tracts, duration, cause

Kidney stones

Mass of crystals, protein, or other substances that form within and may obstruct the urinary tract Classified according to mineral: - Calcium oxalate or phosphate - Struvite - Uric acid

Azotemia

Medical condition characterized by abnormally high levels of nitrogen-containing compounds (such as urea, creatinine, ammonia) in the blood

Diabetic nephropathy

Most common cause of chronic kidney disease and end-stage renal failure Develops from metabolic and vascular complications of DM

Risk factors for severe post-obstructive diuresis

Nephrogenic diabetes insipidus Hypertension Edema Weight gain CHF Uremic encephalopathy

Painful Bladder Syndrome/Interstitial Cystitis Manifestations

Occurs in women 20-30 yrs old Bladder fullness, frequency, small urine volume, chronic pelvic pain with symptoms lasting longer than 9 months

Classifications of Acute Kidney Injury

Prerenal - Renal hypoperfusion - GFR declines because of the decrease in filtration pressure - If prerenal failure goes on too long, can become intrarenal failure b/c tubules are dead (tubular necrosis) Intrarenal - Kidneys themselves are diseased or dead - Usually results from ischemic acute tubular necrosis related to pre renal AKI, nephrotoxic ATN, acute glomerulonephritis, vascular disease, etc. Postrenal - Occurs with urinary tract obstructions that affect the kidneys bilaterally (i.e. kidney stone - Relieve obstruction, urine flows and kidneys come back to life (leading causes: diabetes, high BP)

What is the most common cause of urinary tract obstruction in males?

Prostate hypertrophy

Post-obstructive diuresis

Rapid excretion of large volumes of water, sodium, or other electrolytes, resulting in urine output >10L/day Causes dehydration

End-state renal failure

Renal function of less than 10% requiring dialysis or transplant

Renal failure

Significant loss of renal function requiring dialysis ESRF

Acute Kidney Injury

Sudden decline in kidney function with decrease in glomerular filtration and accumulation of nitrogenous waste products in the blood as demonstrated by an elevation in plasma creatinine and blood urea nitrogen levels (BUN)

Hydronephrosis

Swelling of kidney

Hydroureter

Swelling of ureter

Overactive Bladder Syndrome

Syndrome of detrusor overactivity characterized by urgency with involuntary detrusor contractions during bladder filling phase S/s: Frequency, urgency, nocturia Can be from cystitis