# A nurse is caring for a client with acute glomerulonephritis. Which nursing intervention should be the highest priority?

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> subject: Adult Health

## 문제

A nurse is caring for a client with acute glomerulonephritis. Which nursing intervention should be the highest priority?

## 보기

1. Encourage increased fluid intake to prevent dehydration
2. Administer prescribed antibiotics to treat the underlying infection
3. Provide a high-protein diet to replace protein losses
4. Monitor blood pressure and implement measures to control hypertension **✔ 정답**

**정답: 4**

## 해설

Hypertension is a critical complication in acute glomerulonephritis, requiring priority monitoring and control to prevent cardiovascular and renal damage. Other interventions like fluid intake, antibiotics, or high-protein diet are not primary priorities in this context.

## 심화 해설

Understanding Acute Glomerulonephritis

Acute glomerulonephritis, particularly infection-related glomerulonephritis (IRGN) such as post-streptococcal glomerulonephritis (PSGN), involves inflammation of the glomeruli. This inflammatory process damages the capillary walls, reducing the kidney's ability to filter blood effectively. The result is a classic clinical picture: a sudden drop in glomerular filtration rate (GFR) leads to sodium and water retention, which directly causes fluid volume excess. This manifests as hypertension, edema, and in severe cases, life-threatening pulmonary edema [1,2,3].

Priority Setting: Safety and the Nursing Process

For the NCLEX-RN, establishing priorities requires using frameworks like Maslow's Hierarchy of Needs and the ABCs (Airway, Breathing, Circulation). A client with acute glomerulonephritis is at high risk for complications stemming directly from circulatory overload and hypertension. The highest priority intervention is the one that monitors for and detects these life-threatening complications early. The AsPNA Clinical Practice Guidelines emphasize that management is primarily supportive, with a key focus on managing hypertension and fluid overload to prevent complications like hypertensive encephalopathy and pulmonary edema [1]. Monitoring blood pressure and assessing for signs of fluid overload (such as crackles in the lungs, dyspnea, and worsening edema) is a direct safety measure that addresses the "Circulation" and "Breathing" components of the ABCs [2,3].

Analysis of Options

*   Option 1: Encourage increased fluid intake. This is contraindicated. The core pathophysiology is fluid retention due to a decreased GFR. Increasing intake would worsen hypervolemia, hypertension, and the risk of pulmonary edema [1,2].

Option 2: Administer prescribed antibiotics. While treating an underlying infection (e.g., Group A Streptococcus) is a medical intervention, it is not the nurse's highest independent* priority for a client in the acute phase. The glomerular injury is immune-complex mediated and occurs after the infection has resolved or is resolving; antibiotics address the trigger but not the immediate, life-threatening complications of fluid overload and hypertension [1,3].

*   Option 3: Provide a high-protein diet. This is inappropriate. In acute glomerulonephritis, protein loss in the urine is typically not massive enough to warrant protein replacement. More importantly, a high-protein diet would increase the workload on the already damaged kidneys. Management guidelines focus on sodium and fluid restriction, not protein loading [1].

*   Option 4: Monitor blood pressure and assess for signs of fluid overload. This is the correct priority. The primary dangers in the acute phase are complications of hypervolemia. A case report of PSGN highlighted a child presenting with critical hyperkalemia and acute pulmonary edema, underscoring the rapid and severe nature of fluid overload in this condition [2]. Another case documented an adolescent with hypertension and concurrent pleural and pericardial effusions, demonstrating that fluid can accumulate in multiple compartments, directly threatening respiratory and cardiac function [3]. Continuous monitoring is essential for early detection and timely intervention to prevent respiratory failure and hypertensive crisis.References (research sources)

- [1]AsPNA Clinical Practice Guidelines for the management of infection-related glomerulonephritis.GuidelineMeena J, Sinha A, Krishnasamy S, Alba AA, Aziz MA, Begum A, Chan EY, Kari JA, Pattaragarn A, Perera I, Shen Q, Singh G, Bagga A, Glomerular Disease Working Group, Asian Pediatric Nephrology Association. (2026) · DOI: 10.1007/s00467-026-07146-4

- [2]Post-streptococcal Glomerulonephritis Presenting With Acute Pulmonary Edema and Critical Hyperkalemia: A Rare Pediatric Case Report From Yemen.Case reportMohamed AAA, Ayish MKM, Muafa HM. (2026) · DOI: 10.1177/11795476261444444

- [3]Case Report: A classical PSGN case with unusually prominent serosal manifestations and complement patterns that mimicked systemic autoimmune disease-highlighting diagnostic pitfalls and biopsy decision-making.Case reportJames V, Santy S, Saverimuttu T, Kamath V, Steinberg J. (2026) · DOI: 10.3389/fped.2026.1759332

## 임상 시나리오

Clinical Priority in Acute Glomerulonephritis

A client with acute glomerulonephritis is at immediate risk for life-threatening complications due to fluid volume excess. The primary pathophysiological concern is the retention of sodium and water caused by a reduced glomerular filtration rate (GFR). This directly leads to the most critical clinical manifestation: **severe hypertension**.

Pathophysiology & Risk

- Immune complex deposition triggers glomerular inflammation.

- Damaged glomeruli reduce GFR, causing sodium and water retention.

- Fluid volume excess manifests as hypertension, edema, and dyspnea.

- Uncontrolled hypertension can rapidly progress to **hypertensive encephalopathy** or **acute pulmonary edema**.

Priority Nursing Actions

- **Monitor:** Blood pressure every 2–4 hours, daily weights, intake and output, and lung sounds.

- **Intervene:** Administer prescribed antihypertensives promptly.

- **Restrict:** Fluid and sodium intake as ordered.

- **Assess:** Neurological status for signs of cerebral edema (headache, visual changes, altered mental status).

**Safety Alert:** Do not encourage increased fluid intake. The priority is to manage fluid overload, not correct dehydration. A high-protein diet is also contraindicated as it increases renal workload.

## 핵심 개념

- **Glomerulonephritis** — Inflammation of the glomeruli, often post-streptococcal, caused by immune complex deposition leading to decreased GFR and fluid retention.
- **Priority Setting** — Using frameworks like ABCs or Maslow, the most life-threatening condition (e.g., severe hypertension) is addressed first.
- **Fluid Volume Excess** — A state of hypervolemia resulting from the kidneys' inability to excrete sodium and water, leading to hypertension and edema.
- **Hypertensive Encephalopathy** — A severe complication of uncontrolled hypertension causing cerebral edema, presenting with headache, confusion, and seizures.

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