# 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?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=541464  
> language: ko  
> subject: 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?

## 보기

1. Blood pressure of 180/110 mmHg with complaints of severe headache and blurred vision **✔ 정답**
2. Urine output of 400 mL in the past 24 hours with 3+ proteinuria
3. Periorbital edema and bilateral lower extremity pitting edema
4. Serum creatinine level of 2.8 mg/dL and BUN of 45 mg/dL

**정답: 1**

## 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

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, "**H**eadache + **H**ypertension = **H**igh 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 Scenario

A 45-year-old client with acute glomerulonephritis develops a blood pressure of 180/110 mmHg and reports a sudden, severe headache and blurred vision. These are classic prodromal signs of posterior reversible encephalopathy syndrome (PRES), a hypertensive emergency. The nurse must recognize that cerebral autoregulation is failing, leading to vasogenic edema and imminent risk of seizure or altered mental status. Immediate notification of the provider and preparation for rapid blood pressure reduction are the highest priorities.

Immediate Nursing Actions

- **Notify the provider immediately** and prepare to administer intravenous antihypertensive agents as prescribed (e.g., labetalol, nicardipine, or clevidipine) to lower mean arterial pressure by no more than 25% within the first hour.

- **Ensure IV access** and place the client on continuous cardiac and blood pressure monitoring with an arterial line if available.

- **Perform frequent neurological checks** (every 5-15 minutes), including level of consciousness, pupillary response, and motor strength, to detect progression to seizure or intracranial hemorrhage.

- **Implement seizure precautions:** pad side rails, ensure suction equipment and oxygen are at the bedside, and keep the bed in the lowest position.

- **Maintain a quiet, low-stimulation environment** with dim lighting to minimize triggers for further blood pressure elevation and neurological irritation.

Ongoing Monitoring and Rationale

- **Blood pressure targets:** Aim for a gradual reduction to around 160/100 mmHg over the first few hours. Avoid rapid or excessive drops, which can cause cerebral or renal hypoperfusion.

- **Urine output and fluid balance:** Strict intake and output monitoring is essential. Oliguria is expected, but an abrupt decline to anuria may signal rapidly progressive glomerulonephritis or renal artery hypoperfusion from overly aggressive blood pressure lowering.

- **Daily weights and edema assessment:** Document the extent of periorbital and peripheral edema to evaluate fluid retention trends and response to diuretic therapy, which may be prescribed after the acute hypertensive crisis is controlled.

- **Laboratory trends:** Monitor serum creatinine, BUN, and electrolytes daily. A rising creatinine may indicate worsening glomerular injury, while electrolyte imbalances (especially hyperkalemia) can precipitate cardiac arrhythmias.

Patient Education Points

- Teach the client to report any return of headache, vision changes, confusion, or seizure activity immediately, as these indicate recurrent cerebral edema.

- Explain the importance of strict fluid and sodium restriction as prescribed to manage volume overload and hypertension.

- Instruct on the purpose and common side effects of antihypertensive medications, emphasizing adherence even after discharge to prevent recurrence.

## 핵심 개념

- **Hypertensive Emergency** — A severe increase in blood pressure (often >180/120 mmHg) associated with acute target organ damage, such as encephalopathy, retinal hemorrhage, or renal failure, requiring immediate blood pressure reduction.
- **Posterior Reversible Encephalopathy Syndrome (PRES)** — A clinical-radiological syndrome characterized by headache, seizures, altered mental status, and visual disturbances, caused by vasogenic cerebral edema, often triggered by acute hypertension.
- **Acute Glomerulonephritis** — An inflammatory condition of the glomeruli leading to hematuria, proteinuria, oliguria, edema, and hypertension due to sodium and water retention and activation of the renin-angiotensin-aldosterone system.

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