A nurse is assessing a 45-year-old client diagnosed with acu… | 마이메르시 MyMerci
Adult Health
문제
A nurse is assessing a 45-year-old client diagnosed with acute glomerulonephritis. Which assessment finding would be the MOST concerning and require immediate nursing intervention?
1Blood pressure of 180/110 mmHg with complaints of severe headache and blurred vision✓ 정답
2Urine output of 400 mL in the past 24 hours with 3+ proteinuria
3Periorbital edema and bilateral lower extremity pitting edema
4Serum creatinine level of 2.8 mg/dL and BUN of 45 mg/dL
해설
Severe hypertension with neurological symptoms indicates potential hypertensive crisis, requiring immediate intervention to prevent stroke. Other findings are concerning but not immediate emergencies.
심화 해설
Core Nursing ExplanationKey Concept Analysis: This question assesses the ability to prioritize life-threatening complications in 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 (elevated BUN and creatinine). The core of this question is identifying which finding represents an immediate threat to life or organ function requiring urgent action.
Answer Rationale: Key Point! Option ① is correct because it describes a hypertensive emergency. A blood pressure of 180/110 mmHg with neurological symptoms (severe headache, blurred vision) indicates severe hypertension that is causing end-organ damage, specifically to the brain. This is a medical emergency due to the high risk of hypertensive encephalopathy, intracranial hemorrhage, or stroke. Immediate nursing intervention (e.g., notifying the provider, administering ordered antihypertensives, ensuring safety) is required to lower the pressure in a controlled manner and prevent permanent neurological injury.
Distractor Analysis:
Watch out for confusion! Option ② (Oliguria and proteinuria) and Option ④ (Elevated creatinine and BUN) are expected findings in AGN due to the underlying glomerular damage. While they indicate significant renal impairment and require monitoring and management, they are not typically immediate, life-threatening emergencies on their own in this context.
Option ③ (Edema) is also a classic sign of AGN, resulting from sodium and water retention due to decreased glomerular filtration rate (GFR). Periorbital edema is particularly characteristic. Although it requires diuretic therapy and fluid management, it is not the most concerning finding compared to a hypertensive crisis with neurological involvement.
Related Concepts: This question tests the NCLEX-RN priority-setting framework. Always assess for threats to Airway, Breathing, Circulation (ABCs) and neurological integrity first. Here, the severe hypertension threatens cerebral circulation (a "Circulation" and neurological issue), making it the top priority.
Concept Summary
Concept
Description
Clinical Significance in AGN
Acute Glomerulonephritis (AGN)
Inflammation of the glomeruli, often post-infectious.
Severe HTN with evidence of acute end-organ damage.
Priority finding. Requires immediate intervention to prevent stroke, encephalopathy.
Oliguria
Urine output
임상 시나리오
Nursing Clinical Practice GuideClinical Scenario: You are the day-shift nurse for Mr. Johnson, 45, admitted yesterday with AGN. During morning rounds, he reports a sudden, pounding headache and says his vision is "a little blurry." You immediately check his vital signs.
Nursing Intervention Strategy:
1. Immediate Assessment (ABCs & Neuro): Check BP (you find 180/110), heart rate, respirations. Perform a focused neurological assessment: Level of consciousness (LOC) using AVPU or GCS, pupil check, ask about headache severity/location, nausea, motor strength. Keep him in bed with side rails up.
2. Notification & Collaboration: Call the provider STAT with SBAR report: "S: Mr. Johnson, AGN, reporting severe headache and blurred vision. B: BP 180/110, previously 150/90. A: Appears anxious, alert. R: Requesting orders for immediate antihypertensive management."
3. Implementation of Orders: Anticipate IV antihypertensives (e.g., labetalol, nicardipine drip). Administer precisely as ordered, monitoring BP every 5-15 minutes initially. Ensure a quiet, calm environment.
4. Ongoing Monitoring & Safety: Continue frequent neuro checks. Monitor urine output hourly. Educate the patient on the importance of reporting any worsening symptoms.
Patient Safety and Precautions: When administering IV antihypertensives for a hypertensive emergency, the goal is gradual reduction, not normalization. A rapid drop in BP can cause cerebral hypoperfusion and stroke. A typical initial target is to lower mean arterial pressure (MAP) by no more than 20-25% within the first hour.
Nursing Procedure & Medication FlowManaging Hypertensive Emergency in AGN:
1. Assessment: Vital signs, neuro check, headache scale, vision assessment.
2. Planning: Goal is to safely lower BP and prevent neurological injury.
3. Implementation:
- Safety: Bed rest, quiet room.
- Medication: Administer IV antihypertensive via infusion pump. Know the drug, dose, route, rate, and major side effects (e.g., reflex tachycardia, hypotension).
- Monitoring: Continuous cardiac monitoring, frequent BP checks (every 5-15 min initially), strict I&O.
4. Evaluation: Is BP decreasing gradually? Are neuro symptoms improving? Is urine output adequate?
A Word from Your Senior Nurse
"In the real world, a patient with AGN won't have a sign on their forehead saying 'hypertensive emergency.' It's your sharp assessment skills that catch it. That severe headache isn't just a complaint; it's a red flag waving furiously. When you're studying, don't just memorize 'AGN causes hypertension.' Connect it: Hypertension -> can lead to encephalopathy -> presents with headache/blurred vision -> this is an emergency. That clinical reasoning chain is what saves patients and what the NCLEX tests. You are the first line of defense!"
핵심 개념
Acute Glomerulonephritis — Inflammation of the glomeruli in the kidneys, often following a streptococcal infection, characterized by hematuria, proteinuria, edema, hypertension, and azotemia.
Hypertensive Emergency — A severe elevation in blood pressure (often >180/120 mmHg) with evidence of new or worsening end-organ damage (e.g., to the brain, heart, kidneys). Requires immediate treatment to prevent life-threatening complications.
Oliguria — A clinically significant decrease in urine output, typically defined as less than 400 mL per 24 hours in adults. It is a key indicator of impaired renal function.
Azotemia — The buildup of nitrogenous waste products (urea and creatinine) in the blood due to inadequate excretion by the kidneys. It is a laboratory marker of renal dysfunction.
Glomerular Filtration Rate — The rate at which fluid is filtered through the glomerular capillaries into Bowman's capsule per minute. It is the best overall index of kidney function. A decreased GFR is the hallmark of renal failure.
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