# A nurse is caring for a 28-year-old client with acute post-streptococcal glomerulonephritis following a recent throat infection, who presents with periorbital edema, hypertension (160/95 mmHg), oliguria, and hematuria. Which nursing intervention should be the highest priority?

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## 문제

A nurse is caring for a 28-year-old client with acute post-streptococcal glomerulonephritis following a recent throat infection, who presents with periorbital edema, hypertension (160/95 mmHg), oliguria, and hematuria. Which nursing intervention should be the highest priority?

A 28-year-old client is admitted with acute post-streptococcal glomerulonephritis following a recent throat infection. The client presents with periorbital edema, hypertension (160/95 mmHg), oliguria, and hematuria.

## 보기

1. Monitor blood pressure and implement antihypertensive therapy as prescribed **✔ 정답**
2. Encourage increased fluid intake to promote kidney function
3. Administer high-protein diet to replace lost proteins
4. Provide frequent ambulation to prevent complications

**정답: 1**

## 해설

Hypertension is a life-threatening complication in acute glomerulonephritis, requiring immediate monitoring and antihypertensive therapy to prevent stroke or heart failure. Other options like increased fluids or high-protein diet are not priority in this acute setting.

## 심화 해설

Clinical Context and Priority Setting

This client presents with the classic nephritic syndrome triad following a throat infection: hypertension, edema, and hematuria. The blood pressure reading of 160/95 mmHg represents stage 2 hypertension and is the most immediately dangerous element in this presentation. In acute post-streptococcal glomerulonephritis (APSGN), hypertension results from sodium and water retention caused by decreased glomerular filtration, which directly increases the risk of hypertensive encephalopathy, cardiac failure, and cerebrovascular events. The immune-mediated glomerular injury, triggered by nephritogenic strains of group A beta-haemolytic streptococcus, activates the alternate complement pathway and leads to a proliferative glomerulonephritis that reduces the kidneys' ability to excrete sodium and water [1].

Analysis of the Correct Answer

Monitoring blood pressure and implementing prescribed antihypertensive therapy is the highest priority because uncontrolled hypertension in APSGN can rapidly progress to life-threatening complications. The pathogenesis of hypertension in this condition is primarily volume-dependent; the inflamed glomeruli cannot filter effectively, leading to oliguria and fluid overload. This expanded intravascular volume increases systemic vascular resistance and blood pressure . When blood pressure reaches 160/95 mmHg, the risk of posterior reversible encephalopathy syndrome, seizures, and intracranial hemorrhage rises substantially. Antihypertensive management, often with loop diuretics to address the volume component and vasodilators or calcium channel blockers for afterload reduction, directly mitigates these risks. The nurse must obtain frequent blood pressure readings, assess for neurological changes indicating hypertensive encephalopathy, and administer medications as prescribed without delay.

Why the Other Options Are Incorrect

**Option 2: Encouraging increased fluid intake** is contraindicated. The client is already oliguric due to reduced glomerular filtration, and periorbital edema signals existing fluid overload. Additional fluid would worsen hypertension, exacerbate edema, and potentially precipitate pulmonary edema or heart failure. Management of APSGN centers on fluid *restriction* until urine output recovers, not fluid promotion .

**Option 3: Administering a high-protein diet** reflects a misunderstanding of the pathophysiology. Although proteinuria can occur in APSGN, the protein loss is generally not massive enough to cause significant hypoalbuminemia as seen in nephrotic syndrome. More importantly, the injured glomeruli are already under inflammatory stress; a high protein load increases glomerular hyperfiltration and can worsen tubular injury. Standard practice is to provide a diet with moderate protein, restricted sodium, and potassium monitoring until renal function stabilizes [1].

**Option 4: Providing frequent ambulation** is inappropriate during the acute phase. The client has severe hypertension and is at risk for complications with exertion. Bed rest or limited activity is typically recommended to reduce cardiac workload and blood pressure until the acute episode resolves. Ambulation does not address the underlying volume overload or hypertension and could trigger a hypertensive crisis .

Pathophysiology-to-Practice Connection

APSGN develops when immune complexes deposit in the glomerular basement membrane following a streptococcal infection, activating complement and attracting inflammatory cells. This proliferative process narrows the capillary lumens, reducing the glomerular filtration rate [1]. The kidneys respond by avidly retaining sodium and water, producing the oliguria, edema, and hypertension observed in this client. Hematuria results from the damaged, inflamed capillary walls allowing red blood cells to escape into the urinary space. Understanding this mechanism clarifies why blood pressure control—through diuresis and direct vasodilation—is the cornerstone of acute management. As the glomerular inflammation subsides over days to weeks, spontaneous diuresis typically occurs, and blood pressure normalizes. The nurse's role is to protect the client from hypertensive complications during this vulnerable window by vigilant monitoring and timely medication administration .References (research sources)

- [1]Acute post-streptococcal glomerulonephritis in children-treatment standard.Research articleDhakal AK, Shrestha D, Preston R, Lennon R. (2025) · DOI: 10.1093/ndt/gfaf130

## 임상 시나리오

Managing Hypertension in Acute GlomerulonephritisPriority nursing actions for the nephritic patient
The highest priority is blood pressure control. In APSGN, hypertension is volume-dependent due to sodium and water retention from reduced GFR. A reading of 160/95 mmHg demands immediate intervention to prevent hypertensive encephalopathy and cardiac failure.

Core interventions include strict intake and output monitoring, daily weights, and administering prescribed antihypertensives and diuretics. Fluid and sodium restriction is essential to reduce volume overload.

CautionDo not encourage fluids; this worsens edema and hypertension. Avoid high-protein diets which increase renal workload. Prioritize bed rest during the acute phase to promote diuresis and reduce stress on the kidneys.

## 핵심 개념

- **Acute Post-Streptococcal Glomerulonephritis (APSGN)** — An immune-mediated inflammation of the glomeruli following infection with nephritogenic strains of group A beta-hemolytic streptococcus, characterized by a sudden onset of hematuria, proteinuria, edema, hypertension, and oliguria.
- **Oliguria** — Reduced urine output, typically defined as less than 400 mL per day in adults, resulting from decreased glomerular filtration in this context.
- **Nephritic Syndrome** — A clinical syndrome characterized by hematuria, mild to moderate proteinuria, hypertension, edema, and reduced kidney function due to glomerular inflammation.
- **Hypertensive Encephalopathy** — A life-threatening neurological emergency caused by severely elevated blood pressure, leading to cerebral edema and symptoms such as headache, confusion, seizures, and coma.

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