A nurse is assessing a 45-year-old client diagnosed with acute glomerulonephritis. Which assessment finding would be the MOST concerning and require immediate intervention?
1Periorbital edema that resolves by midday
2Urine output of 400 mL over the past 8 hours
3Blood pressure of 180/110 mmHg with severe headache✓ 정답
4Proteinuria of 2+ on dipstick urinalysis
해설
Severe hypertension (180/110 mmHg) with headache indicates hypertensive crisis requiring immediate intervention to prevent stroke or seizures. Other findings are expected in acute glomerulonephritis but less urgent.
Clinical Judgment
This question evaluates prioritization and clinical judgment. When multiple abnormal findings are present in a patient with acute glomerulonephritis, you must identify the most dangerous finding requiring immediate intervention. The key is assessing the risk of life-threatening complications. In option 3, "blood pressure 180/110 mmHg with severe headache" is a sign of hypertensive crisis and hypertensive encephalopathy, which can lead to fatal outcomes such as stroke or seizures, thus requiring the most urgent intervention. The other findings are typical symptoms of the disease but do not pose an immediate threat to life.
Memory Tip:
Remember Notify HCP! In acute glomerulonephritis, "Headache + Hypertension = High priority." When the two H's appear together, it can be a hazard to the brain.
KR vs US
In Korea, protocols for initial response and monitoring of hypertensive crisis patients may be systematized, but in the NGN/US exam, the emphasis is on the nurse's independent judgment and immediate reporting to the healthcare provider (Notify HCP). The core is the ability to assess risk and act based on the combination of a subjective symptom ("severe headache") and an objective value (hypertension).
임상 시나리오
Clinical Practice Guide
The core of nursing care for patients with acute glomerulonephritis is managing fluid overload and hypertension. Weight, vital signs (especially blood pressure), peripheral edema, breath sounds, and daily intake and output (I&O) should be monitored regularly. Proteinuria and hematuria are markers of the disease but are not direct life threats.
Caution
In SATA (Select All That Apply) questions, when asked to choose the "most concerning" finding, you must select only one. Do not list all abnormal findings; instead, prioritize findings directly linked to ABC (airway, breathing, circulation) or neurological threats. "Severe headache" is a strong clue that there may be a problem with cerebral perfusion.
핵심 개념
Acute Glomerulonephritis — Acute glomerulonephritis. An acute inflammatory disease of the renal glomeruli that mainly occurs after infection with Group A beta-hemolytic streptococcus. Glomerular filtration impairment occurs due to immune complex deposition.
Hypertensive Crisis — Hypertensive crisis. A rapid and severe increase in blood pressure, defined as systolic blood pressure >180 mmHg and/or diastolic blood pressure >120 mmHg. There is a high risk of end-organ damage (brain, heart, kidneys), requiring immediate treatment.
Hypertensive Encephalopathy — Hypertensive encephalopathy. This is an emergency condition caused by failure of the brain's autoregulation mechanism for perfusion due to extreme high blood pressure, and it can lead to headache, nausea, visual disturbances, altered level of consciousness, and seizures.
Oliguria — Oliguria. In adults, a condition where urine output is less than 400 mL over 24 hours or less than 0.5 mL/kg per hour. It is an important sign of decreased kidney function.
Proteinuria — Proteinuria. A condition in which an abnormal amount of protein (mainly albumin) is excreted in the urine. It is used as a marker of glomerular damage or filtration disorder.