# A nurse is caring for a client with acute pyelonephritis. Which assessment finding requires the most immediate nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541461 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client with acute pyelonephritis. Which assessment finding requires the most immediate nursing intervention? ## 보기 1. Temperature of 103.2°F (39.6°C) with shaking chills **✔ 정답** 2. Flank pain rated 7/10 on the pain scale 3. Cloudy urine with a strong odor 4. Nausea and decreased appetite **정답: 1** ## 해설 Temperature of 103.2°F with shaking chills indicates potential sepsis, a life-threatening complication requiring immediate intervention. Other findings are expected in pyelonephritis but less urgent. ## 심화 해설 Analysis of the Priority Assessment Finding The client with acute pyelonephritis is at risk for rapid clinical deterioration due to the systemic inflammatory response and potential for sepsis. When prioritizing care using the ABC (Airway, Breathing, Circulation) framework and the concept of systemic versus localized symptoms, the nurse must identify findings that indicate a threat to hemodynamic stability and systemic infection. A temperature of 103.2°F (39.6°C) with shaking chills (rigors) is the most critical finding because it signifies bacteremia and a profound systemic response, which can quickly progress to septic shock if not immediately addressed [1]. Pathophysiological Rationale Shaking chills are a physiological mechanism where the hypothalamus raises the body's temperature set point in response to circulating pyrogens, such as the lipopolysaccharides released by gram-negative bacteria like Escherichia coli. This triggers intense muscle contractions to generate heat, which dramatically increases metabolic demand and oxygen consumption. In the context of acute pyelonephritis, this finding indicates that the infection has moved beyond the renal parenchyma and collecting system into the bloodstream. The resulting systemic vasodilation and increased capillary permeability can lead to relative hypovolemia and hypotension, compromising perfusion to vital organs, including the kidneys themselves. This is particularly dangerous as it can precipitate acute kidney injury (AKI), as demonstrated in a case where a patient with pyelonephritis and E. coli infection progressed to anuria secondary to acute tubulointerstitial nephritis [1]. While the patient's temperature initially normalized with anti-infective therapy, the progressive decrease in urine output highlights how the initial systemic infectious insult can trigger a cascade of inflammatory damage within the kidneys, a risk that begins with the bacteremia signaled by high fever and rigors [1]. Why Other Options Are Not the Immediate Priority Flank pain rated 7/10 is a classic and expected finding in pyelonephritis due to inflammation and stretching of the renal capsule. While significant and requiring prompt analgesic intervention for comfort, it is a localized symptom and does not represent an immediate threat to the patient's airway, breathing, or circulatory status. Similarly, cloudy urine with a strong odor is a common manifestation of pyuria and bacteriuria, confirming the presence of infection but not indicating a systemic emergency. Nausea and decreased appetite are nonspecific constitutional symptoms of infection and uremia but do not take priority over a sign of systemic instability. The diagnostic challenge in acute settings is differentiating a severe localized infection from one that has triggered a systemic and potentially life-threatening response, such as the spontaneous renal hemorrhage seen in Wunderlich syndrome, which can present with severe flank pain and hemodynamic instability . In this scenario, the high fever with rigors is the earliest and most critical indicator of that dangerous systemic transition. References (research sources) - [1]Case Report: Uremia secondary to acute pyelonephritis in a patient with type 2 diabetes mellitus.Case reportXu Z, Yin F, Zhao L, Hou Q, Han G, Wang J, Zhang K. (2026) · DOI: 10.3389/fmed.2026.1764853 ## 임상 시나리오 Sepsis Recognition in PyelonephritisPrioritizing Systemic vs. Localized Findings In acute pyelonephritis, a temperature of 103.2°F (39.6°C) with rigors is the priority finding. This indicates bacteremia and a systemic inflammatory response that can rapidly progress to septic shock. Use the ABC framework to prioritize. Systemic signs (fever with rigors, hypotension, altered mental status) always take precedence over localized symptoms (flank pain, cloudy urine) because they signal an immediate threat to hemodynamic stability. CautionDo not delay intervention for rigors and high fever to manage pain or nausea first. Immediate actions include obtaining blood cultures, administering prescribed antipyretics and antibiotics, and monitoring for hypotension and altered mental status. ## 핵심 개념 - **Rigors** — A profound shaking chill accompanied by chattering of teeth and severe shivering, indicating a systemic response to circulating pyrogens and often a sign of bacteremia. - **Bacteremia** — The presence of viable bacteria in the bloodstream, which can trigger a systemic inflammatory response and progress to sepsis and septic shock. - **ABC Framework** — A prioritization model in nursing that guides assessment and intervention by addressing Airway, Breathing, and Circulation first, as threats to these are immediately life-threatening. - **Pyelonephritis** — An infection of the renal pelvis, tubules, and interstitial tissue, typically caused by ascending bacteria, leading to systemic and localized symptoms. - **Septic Shock** — A subset of sepsis with profound circulatory, cellular, and metabolic abnormalities, characterized by persistent hypotension requiring vasopressors and elevated lactate levels despite adequate fluid resuscitation. ## 같은 주제 문제 - [A nurse is assessing a 45-year-old female client who presents to the emergency department …](https://mymerci.kr/pages/nclex_q.php?qn_id=541456) - [A 45-year-old female patient is admitted to the medical unit with suspected acute pyelonep…](https://mymerci.kr/pages/nclex_q.php?qn_id=541457) - [A nurse is caring for a client diagnosed with acute pyelonephritis. 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