A nurse is caring for a client with acute post-streptococcal glomerulonephritis. Which nursing action should be the highest priority?
A 28-year-old client is admitted with acute post-streptococcal glomerulonephritis following a recent throat infection. The client presents with periorbital edema, hypertension (160/95 mmHg), and dark-colored urine.
1Encourage increased fluid intake to prevent dehydration
2Monitor blood pressure and assess for signs of hypertensive crisis✓ 정답
3Administer diuretics to reduce edema immediately
4Prepare the client for immediate dialysis
해설
Monitoring blood pressure is the highest priority due to the risk of hypertensive crisis, which can lead to life-threatening complications like encephalopathy or stroke. Other options are less urgent or inappropriate without specific orders.
Core Nursing ExplanationKey Concept Analysis: This question assesses priority nursing intervention for a patient with Acute Post-Streptococcal Glomerulonephritis (APSGN). The core pathophysiology involves an immune complex-mediated inflammation of the glomeruli following a streptococcal infection (like strep throat). This inflammation impairs the kidney's ability to filter blood, leading to three hallmark problems: fluid retention (edema), hypertension, and hematuria/proteinuria.
Answer Rationale: Key Point! The highest priority is Monitoring blood pressure and assessing for signs of hypertensive crisis. The patient's BP is 160/95 mmHg, indicating significant hypertension. In APSGN, hypertension results from sodium and water retention due to decreased glomerular filtration rate (GFR). Uncontrolled, severe hypertension can rapidly progress to hypertensive encephalopathy (causing headache, seizures, altered mental status) or increase the risk of stroke or heart failure. Therefore, vigilant monitoring and early intervention to control BP are critical for preventing these life-threatening neurological and cardiovascular complications.
Distractor Analysis:
Watch out for confusion! Option ①, "Encourage increased fluid intake," is generally contraindicated in APSGN. The patient is already fluid-overloaded (evidenced by edema and hypertension). Increasing fluids would worsen hypertension and edema. Fluid restriction is often part of the management plan.
Option ③, "Administer diuretics to reduce edema immediately," is an important intervention but is not the independent, highest-priority nursing action. Administering medication requires a physician's order. The nurse's priority is continuous assessment and monitoring to inform treatment. While diuretics like furosemide may be used, controlling the underlying hypertension is more immediately critical.
Option ④, "Prepare the client for immediate dialysis," is incorrect for typical APSGN. While APSGN can cause acute kidney injury, most cases in children and young adults (like this 28-year-old) are self-limiting and managed conservatively. Dialysis is reserved for severe complications like hyperkalemia, severe fluid overload unresponsive to diuretics, or uremia—none of which are indicated in the scenario.
Related Concepts: The nursing priorities in APSGN follow the ABC (Airway, Breathing, Circulation) framework. Hypertension is a direct threat to "Circulation" and brain perfusion. Management focuses on restricting sodium and fluid intake, administering antihypertensives and diuretics as ordered, monitoring intake and output (I&O), and assessing for complications. The dark-colored urine is due to hematuria, a classic sign.Nursing Clinical Practice GuideClinical Scenario: You are the nurse on a medical-surgical unit. Your patient, a 28-year-old, was admitted with facial puffiness, headache, and cola-colored urine 2 weeks after recovering from a sore throat. Vital signs on admission: BP 160/95, HR 88, RR 18. You note 2+ pitting edema around the eyes and ankles.
Nursing Intervention Strategy:
Assessment (Priority): Perform frequent neurovascular checks (headache, vision changes, confusion) alongside BP monitoring every 1-2 hours initially. Accurately measure and document intake and output (I&O) and daily weights to track fluid status.
Care & Education: Collaborate with dietary services to implement a strict low-sodium, fluid-restricted diet as ordered. Educate the patient on the importance of this diet to control BP and edema. Provide meticulous skin care due to edema.
Medication Administration: Administer antihypertensives (e.g., ACE inhibitors) and diuretics as prescribed. Monitor for effectiveness (decreased BP, increased urine output) and side effects (electrolyte imbalances, orthostatic hypotension).
Patient Safety and Precautions: Never encourage fluid intake without an order. Be alert for signs of worsening hypertension: severe headache, vomiting, blurred vision, or seizures—report these immediately. Monitor lab values closely, especially potassium levels if on diuretics and BUN/Creatinine to assess kidney function.
Nursing Procedure & Medication Flow
When administering loop diuretics like furosemide (Lasix):
Administer in the morning to avoid nocturia.
Monitor for hypokalemia (muscle weakness, cramps, arrhythmias).
Assess for hearing changes (ototoxicity risk with rapid IV push).
Ensure the patient has easy access to a bathroom or bedpan after administration.
A Word from Your Senior Nurse
"In glomerulonephritis, the kidneys are struggling. Your job is to be their advocate and protector. That elevated blood pressure isn't just a number—it's a warning sign that pressure is building up inside the delicate vessels of the brain. Catching a rising trend early and intervening can prevent a catastrophic neurological event. Always connect the dots: edema + hypertension + dark urine = kidneys in trouble. Your vigilant monitoring is the first line of defense."
Acute Post-Streptococcal Glomerulonephritis — An immune-complex mediated inflammation of the kidney glomeruli occurring 1-3 weeks after a Group A beta-hemolytic streptococcal infection (e.g., pharyngitis). Characterized by the triad of edema, hypertension, and hematuria.
Hypertensive Encephalopathy — A medical emergency caused by a rapid and severe rise in blood pressure leading to cerebral edema and neurological dysfunction (headache, vomiting, confusion, seizures, coma). It is a critical complication to prevent in APSGN.
Glomerular Filtration Rate — The rate at which blood is filtered through the glomeruli of the kidneys. In APSGN, inflammation decreases GFR, leading to sodium/water retention (causing edema/hypertension) and accumulation of waste products.
Hematuria — The presence of red blood cells in the urine. In APSGN, it gives the urine a smoky, cola-colored, or tea-colored appearance due to leakage from damaged glomeruli.
Fluid Volume Excess — A nursing diagnosis related to the abnormal retention of fluid and sodium. In APSGN, it manifests as edema (periorbital, dependent), hypertension, and weight gain. Management involves sodium/fluid restriction and diuretics.
Concept Summary
Problem
Pathophysiological Cause
Clinical Manifestation
Nursing Priority
Hypertension
Decreased GFR → Sodium/Water Retention → Increased Blood Volume
High BP (160/95), Risk of encephalopathy/stroke
Monitor BP, Neuro checks
Edema
Fluid shift into interstitial spaces due to low plasma oncotic pressure (proteinuria) and sodium retention
Periorbital edema, weight gain
I&O, Daily weights, Low-Na diet
Urinary Changes
Inflamed glomeruli become leaky to RBCs and protein