Nokea
A child is brought into the clinic with symptoms of edema and dark brown rusty urine. Which nursing assessment finding would best assist in determining the cause of this problem?
- A. Sore throat 2 weeks ago
- B. Red blood cells in the urine
- C. Elevation of blood pressure
- D. Protein elevation in the urine
Correct Answer: A
Rationale: Acute glomerulonephritis usually occurs as a result of bacterial infection such as seen with a beta-hemolytic streptococcal infection or impetigo. Red blood cells and protein found in the urine and elevated blood pressure are symptoms associated with glomerulonephritis.
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A nephrostomy tube is inserted in a client with a large ureteral calculus. Which is the most important consideration in providing nursing care for this client?
- A. Clamp the tube for no longer than 2 hours at a time.
- B. Maintain free, continuous urine drainage.
- C. Leave nephrostomy site open to the air.
- D. Use only sterile NSS to irrigate the tube.
Correct Answer: B
Rationale: Clamping or kinking of the tube will create backup of urine into the renal pelvis, resulting in hydronephrosis and can contribute to renal damage. Always make sure the urine is allowed to flow continuously and freely and do not irrigate. The nephrostomy tube is inserted through a stab wound and enters the kidney. A sterile dressing should be used to prevent pathogen entry.
A client with chronic glomerulonephritis has generalized edema. Which response by the nurse best describes why anasarca occurs with this disorder?
- A. Loss of serum protein causes the body's fluids to shift.
- B. High albumin levels in the blood attracts more fluid into the blood vessels.
- C. Too little sodium in the diet results in anasarca.
- D. When urine is retained in the body, it shifts the body's fluid into tissue spaces.
Correct Answer: A
Rationale: Anasarca is caused by the shift of fluid from the intravascular space to interstitial and intracellular locations, not by a shift of fluid from the tissues into the blood vessels. The fluid shift results from depletion of protein from the blood (serum) to the urine. Sodium intake should be limited in clients with renal disease, and too little sodium intake does not result in anasarca. Urinary retention is not indicated with anasarca.
When assessing a client with chronic glomerulonephritis, the nurse notes that the client has generalized edema. How does the nurse document this?
- A. Periorbital edema
- B. Anasarca
- C. Uremic frost
- D. Hydronephrosis
Correct Answer: B
Rationale: Generalized edema known as anasarca is a common finding with chronic glomerulonephritis. Periorbital edema refers to puffiness around the eyes. Uremic frost is a precipitate that forms on the skin in clients with chronic renal failure. Hydronephrosis refers to a condition involving distention of the renal pelvis.
The nurse is providing education to a client with acute glomerulonephritis. What should the nurse include in the teaching? Select all that apply.
- A. Identify high-sodium foods to include in the diet to increase dietary sodium.
- B. Explain the purpose of diuretic therapy or other prescribed medications, the dosing regimen, and side effects.
- C. Recommend regular blood pressure monitoring.
- D. Caution the client to avoid contact with persons who have infections.
- E. Advise the client that weight gain is an expected outcome.
Correct Answer: B,C,D
Rationale: The nurse should explain the purpose of diuretic therapy or other prescribed medications, the dosing regimen, and side effects, recommend regular blood pressure monitoring, and caution the client to avoid contact with persons who have infections. The nurse should identify the specific amount of sodium that the client is allowed and identify sources of sodium to avoid. The nurse should also advise the client to contact the primary provider if urinary volumes diminish, or if headaches, nosebleeds, or unexpected weight gain occur.
A client is experiencing acute glomerulonephritis. Which assessment finding by the nurse is most important in determining the severity of the client's condition?
- A. Presence of albumin in the urine
- B. Dark smoky colored urine
- C. Blurred vision
- D. Peripheral edema
Correct Answer: C
Rationale: Visual disturbances can be indicative of rising blood pressure in a client with acute glomerulonephritis. Severe hypertension needs prompt treatment to prevent convulsions. Presence of albumin (protein) and RBCs in the urine, along with periorbital and peripheral edema, are common symptoms associated with glomerulonephritis.