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

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## 문제

A nurse is caring for a client with acute post-streptococcal glomerulonephritis. Which nursing action 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), and dark-colored urine.

## 보기

1. Encourage increased fluid intake to prevent dehydration
2. Monitor blood pressure and assess for signs of hypertensive crisis **✔ 정답**
3. Administer diuretics to reduce edema immediately
4. Prepare the client for immediate dialysis

**정답: 2**

## 해설

Monitoring blood pressure is the highest priority due to the risk of hypertensive crisis, which can lead to life-threatening complications like encephalopathy or stroke. Other options are less urgent or inappropriate without specific orders.

## 심화 해설

Understanding the Priority: Why Blood Pressure Monitoring Comes First

In acute post-streptococcal glomerulonephritis (APSGN), the glomeruli are damaged by immune complexes deposited after a group A beta-hemolytic streptococcal infection. This inflammatory injury reduces the glomerular filtration rate (GFR), leading to sodium and water retention. The direct consequence is volume overload, which manifests clinically as hypertension and edema.  The client's blood pressure of 160/95 mmHg is not a minor finding; it represents a state of significant circulatory stress.

The highest priority is to monitor this blood pressure closely and assess for signs of a hypertensive crisis. Uncontrolled hypertension in APSGN can precipitate life-threatening complications, including hypertensive encephalopathy (seizures, altered mental status) and acute pulmonary edema. The pathogenesis, as described in the literature, involves the activation of the alternate complement pathway, which fuels glomerular inflammation and perpetuates fluid retention, directly driving the hypertension.  A case report from Yemen vividly illustrates this danger, where a child with PSGN presented with severe respiratory distress from acute pulmonary edema, a direct complication of unchecked volume overload and hypertension. [2] Therefore, vigilant assessment to detect neurological changes, worsening dyspnea, or a further spike in blood pressure is the most immediate nursing action to prevent irreversible harm.

Why the Other Options Are Not the Priority

Encouraging increased fluid intake would be detrimental. The core pathophysiology of APSGN is fluid volume excess due to impaired renal excretion. Adding more fluid would worsen the hypertension, edema, and the risk of pulmonary congestion. The management goal is fluid and sodium restriction, not replacement.

While diuretics are a cornerstone of medical management to treat volume overload and hypertension, their administration is not the priority nursing action. A nurse must first have a complete set of vital signs and a focused assessment to safely administer and then evaluate the effect of a medication. Administering a diuretic without a current, accurate blood pressure reading and respiratory assessment could precipitate hypotension or fail to address a rapidly deteriorating situation.

Preparing for immediate dialysis is not the first-line intervention. APSGN typically involves a period of oliguria and acute kidney injury (AKI), which is often managed supportively as the glomerular inflammation resolves. Dialysis is reserved for severe, intractable complications of AKI that cannot be managed medically, such as critical hyperkalemia, severe metabolic acidosis, or fluid overload causing pulmonary edema unresponsive to diuretics. [2]  The scenario does not yet indicate that these criteria have been met, making assessment the required first step.

Clinical Correlation with Acute Kidney Injury (AKI)

The dark-colored urine is a classic sign of nephritic sediment, containing red blood cells and casts, which confirms active glomerular inflammation. [2] This inflammation can lead to a rapid decline in renal function. A Moroccan retrospective study of hospitalized children with APSGN highlights that AKI is a common feature requiring careful monitoring of serum creatinine and urine output.  This decline in GFR is the mechanism behind the fluid retention driving the hypertension. Furthermore, as renal function worsens, the clearance of other medications is impaired, creating additional dangers. For instance, a case of an adult with diabetes and PSGN-related AKI demonstrated how impaired renal drug clearance led to profound hypoglycemia from accumulated sulfonylureas.  This underscores why continuous assessment, particularly of neurological status and vital signs, is critical to detect both primary and secondary complications of the disease process.References (research sources)

- [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

## 임상 시나리오

APSGN & Hypertensive Crisis MonitoringPrioritizing Assessment to Prevent End-Organ Damage
In acute post-streptococcal glomerulonephritis (APSGN), immune complex deposition reduces GFR, causing sodium and water retention. This directly leads to volume overload, manifesting as hypertension and edema. A blood pressure of 160/95 mmHg indicates significant circulatory stress.

The highest priority is to monitor blood pressure and assess for hypertensive crisis. Uncontrolled hypertension can precipitate life-threatening complications like hypertensive encephalopathy (seizures, altered mental status) and acute pulmonary edema due to the activation of the alternate complement pathway.

CautionDo not encourage increased fluid intake, as this will worsen volume overload. Diuretic administration requires a provider order and follows initial assessment. Dialysis is not a first-line intervention but reserved for severe, refractory complications.

## 핵심 개념

- **Acute Post-Streptococcal Glomerulonephritis (APSGN)** — Immune complex-mediated glomerular inflammation following group A beta-hemolytic streptococcal infection, causing decreased GFR, sodium/water retention, hypertension, and edema.
- **Hypertensive Crisis** — A severe elevation in blood pressure that can lead to end-organ damage such as hypertensive encephalopathy (seizures, altered mental status) or acute pulmonary edema.
- **Nursing Priority (Assessment vs. Intervention)** — The principle that comprehensive patient assessment and monitoring must precede and guide dependent nursing interventions like medication administration.
- **Volume Overload** — A state of excess fluid and sodium retention in the body, often manifesting as hypertension, edema, and respiratory distress in kidney disorders.
- **Glomerular Filtration Rate (GFR)** — The rate at which blood is filtered by the glomeruli; reduced in APSGN, leading to the accumulation of fluid and waste products.

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