A nurse is caring for a client with acute glomerulonephritis. Which nursing assessment finding requires the most immediate intervention?
1Blood pressure of 180/110 mmHg with complaints of severe headache✓ 정답
2Urine output of 300 mL in the past 8 hours with mild peripheral edema
3Serum creatinine level of 2.1 mg/dL (normal: 0.6-1.2 mg/dL)
4Presence of cola-colored urine with proteinuria on urinalysis
해설
Severe hypertension with headache indicates hypertensive crisis requiring immediate intervention to prevent stroke or seizure. Other findings are expected in acute glomerulonephritis but less urgent.
Core Nursing ExplanationKey Concept Analysis: This question tests the ability to prioritize nursing assessments and interventions for a patient with Acute Glomerulonephritis (AGN). AGN is an inflammatory condition of the glomeruli, often post-streptococcal, leading to impaired kidney function. Key pathophysiological consequences include fluid retention, hypertension, and azotemia (buildup of nitrogenous waste). The core of this question is identifying which finding represents an immediate threat to life (e.g., hypertensive encephalopathy, pulmonary edema) versus expected, chronic manifestations of the disease.
Answer Rationale: Key Point! A blood pressure of 180/110 mmHg accompanied by a severe headache is a classic sign of hypertensive urgency/emergency. In AGN, hypertension results from sodium and water retention (volume overload) and activation of the renin-angiotensin-aldosterone system (RAAS). Severe, uncontrolled hypertension can rapidly progress to hypertensive encephalopathy (causing seizures, altered mental status) or intracranial hemorrhage (stroke). This requires immediate pharmacological intervention (e.g., IV antihypertensives) and monitoring to prevent permanent neurological damage or death.
Distractor Analysis:
Watch out for confusion! Option ②: A urine output of 300 mL in 8 hours (37.5 mL/hr) indicates oliguria, which is an expected finding in AGN due to decreased glomerular filtration rate (GFR). Mild edema is also common. While this requires monitoring and fluid management, it is not an immediate life threat like malignant hypertension.
Option ③: An elevated serum creatinine (2.1 mg/dL) indicates azotemia and reduced kidney function, which is the defining feature of AGN. This is a significant finding that guides diagnosis and long-term management but, by itself, does not signal an acute crisis requiring intervention within minutes.
Option ④: Cola-colored urine (hematuria) and proteinuria are hallmark diagnostic signs of AGN, caused by inflammation and damage to the glomerular capillary walls. These are expected clinical manifestations, not indicators of an immediate emergency.
Related Concepts: The nursing priority framework (e.g., ABCs—Airway, Breathing, Circulation, Maslow's Hierarchy) guides us to address threats to circulation (severe hypertension) and neurological integrity first. In renal disorders, complications like hyperkalemia, pulmonary edema, and hypertensive crisis take precedence over the disease's primary symptoms.
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on a medical unit. A 12-year-old patient, admitted 2 days ago with a diagnosis of post-streptococcal acute glomerulonephritis, calls you to the room complaining of a sudden, pounding headache. You quickly assess their vital signs.
Nursing Intervention Strategy:
1Immediate Assessment & ActionUpon finding BP of 180/110 mmHg and headache, your first action is to stay with the patient, ensure safety, and call for help/notify the provider immediately per protocol. Position the patient with the head of the bed elevated.
2MonitoringInitiate continuous cardiac and blood pressure monitoring. Perform a focused neurological assessment (level of consciousness, pupil response, motor strength, presence of visual disturbances or nausea/vomiting) to screen for encephalopathy.
3Medication AdministrationAnticipate and prepare to administer rapid-acting IV antihypertensive medications as ordered (e.g., labetalol, nicardipine). Administer oral medications carefully if prescribed, monitoring for a controlled reduction in BP (avoiding too rapid a drop).
4Ongoing ManagementImplement strict intake and output (I&O) monitoring, daily weights, and a sodium-restricted diet as ordered. Continue to monitor urine characteristics.
Patient Safety and Precautions:
1Neurological PrecautionsImplement seizure precautions (padded side rails, airway equipment available) due to the risk of hypertensive encephalopathy.
2Medication CautionWhen administering diuretics (e.g., furosemide) for fluid overload, monitor for electrolyte imbalances, especially hypokalemia, and drastic drops in blood pressure.
3Fluid ManagementAdhere strictly to fluid restrictions if ordered. Overhydration can exacerbate hypertension and pulmonary edema.
Nursing Procedure & Medication FlowHypertensive Crisis Response:
1. Assess VS and Neurological status.
2. Notify physician/Rapid Response Team.
3. Administer IV antihypertensive drip as ordered – calculate drip rate accurately, use an infusion pump, and titrate to target BP parameters.
4. Re-assess BP every 5-15 minutes initially.
5. Document thoroughly: baseline assessment, interventions, patient response, and provider notifications.
A Word from Your Senior Nurse
"In real clinical practice, a headache in a glomerulonephritis patient is a huge red flag. Don't just document it and move on—grab the blood pressure cuff immediately! Your rapid assessment and escalation can prevent a stroke. For the NCLEX, always think: 'What can kill my patient first?' Here, it's not the cola-colored urine you learned about in patho class; it's the skyrocketing blood pressure threatening their brain. That's the heart of nursing judgment."
Acute Glomerulonephritis — An inflammatory disease of the glomeruli, often following a streptococcal infection, characterized by hematuria, proteinuria, hypertension, edema, and impaired renal function.
Hypertensive Encephalopathy — A medical emergency caused by severely elevated blood pressure leading to cerebral edema, resulting in headache, confusion, seizures, and visual disturbances.
Oliguria — A decreased urine output, typically defined as less than 400 mL per 24 hours or less than 0.5 mL/kg/hr in adults. A key sign of reduced glomerular filtration rate (GFR).
Azotemia — The buildup of nitrogenous waste products (e.g., BUN, creatinine) in the blood due to impaired kidney function.
Renin-Angiotensin-Aldosterone System — A hormone system that regulates blood pressure and fluid balance. In AGN, it is often inappropriately activated, contributing to hypertension and sodium retention.
Concept SummaryPathophysiology Triad of AGN: Glomerular Inflammation → Impaired Filtration → Fluid Retention (Edema, Hypertension) + Loss of RBCs/Protein (Hematuria/Proteinuria) + Waste Buildup (Azotemia).
Priority Complications: 1. Hypertensive Crisis 2. Pulmonary Edema (from fluid overload) 3. Hyperkalemia (from reduced renal excretion).
Key Nursing Assessments: Frequent BP and neurological checks, strict I&O, daily weights, monitoring for signs of fluid overload (crackles, JVD), and observing urine characteristics.
Side-by-Side Comparison!