ASSIGNMENT 7 WORKSHEET GU / Renal Systems Disorders   Academic honesty reminder:  It is ok to discuss the assignments with other students as a learning tool, but it is considered a breach of academic honesty to copy answers directly from each other.Also, when taking a test, do not have this or any other document visible before you.

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Instructions: 

1.       Read and study RRD #7and any other documents that are referred to.

2.       Fill in this worksheet after you finish your readings.

3.       Click on the Assignment Submission when you are ready to enter your answers, and follow the instructions there.  Note:  the electronic assignment format LOOKS like a test, but you will be able to access the assignment twice UP UNTIL THE DUE DATE.  At the due date and time, the assignment submission module will become inaccessible.   If you have not submitted your assignment by then you will receive a zero.

 

 

1.       A patient with a history of chronic kidney disease sustains a stress fracture of the vertebra.     Her increased risk of this kind of event is most likely due to                             

          a.       dehydration from postrenal AKI.

          b.       osteoporosis from decreased activation of vitamin D.

          c.       osteoporosis from decreased phosphate.

          d.       anemia due to lack of erythropoietin.

 

2.       Over a 30 hour period a patient develops oliguria.  Blood work is done & he is found to have a BUN of 26 and serum creatinine of 1.1.   What type of problem is most likely?                                                                                                  

 

norm BUN = 7 to 25 mg/dl;   norm serum creatinine = 0.6-1.2 mg/dl  (we will use these male levels-- women’s normal  levels are usually lower; you don’t have to memorize these number ranges anyway—they will be provided on the test).

          a.       prerenal acute kidney injury

          b.       acute tubular necrosis

          c.       postrenal chronic kidney injury

          d.       glomerulonephritis

 

3.       Findings consistent with the above problem would be all of the following EXCEPT       

a.       poor skin turgor.

          b.       a urinalysis (UA) that shows an increased urine specific gravity.

          c.       a urinalysis (UA) that shows decreased urine specific gravity.

          d.       hypovolemia.

 

4.       Drugs that ___________should not be used in chronic renal failure (CKD).            

          a.       enhance potassium secretion in the distal convoluted tubule (DCT)

          b.       enhance potassium reabsorption in the DCT

          c.       decrease pruritis.

          d.       enhance diuresis.

 

5.       The reason for the answer above is                                                                

          a.       pruritis is caused by increased urea levels in the blood.

          b.       in CKD aldosterone pathologically increases K+ excretion into the DCT.

          c.       diuresis would increase the risk of hypokalemia.

d.       in CKD, K+ excretion into the DCT is decreased because of pathologic unresponsiveness to aldosterone.

 

 

6.       The parents of a 12-year-old boy who is having surgery to remove a testis that didn’t descend

before birth asks the nurse why the surgery is necessary since his other testis is fine and in the scrotal sac.  The nurse’s explanation is based on the understanding that                         

a.       the retained testis can lead to a urinary obstruction later in life.

          b.       the retained testis can lead to a cancerous condition called cryptorchidism.

          c.       cryptorchidism is a risk factor for testicular cancer.

          d.       having both testes in the scrotal sac is of acute life-threatening importance.

 

7.       A 70 year old man with emphysema develops postrenal AKI.  What is the most likely cause?

          a.       dehydration from chronic hyperventilation.

          b.       a positive PSA.

          c.       benign prostatic hyperplasia.

          d.       a UTI.

 

8.       The patient above develops CKD. His ABGs are: pH 7.32, pCO2 40, HCO3 19, PO2 80. This acid/base imbalance is likely caused by impairment in the kidneys’ ability to        

                  

          a.       buffer respiratory alkalosis.

          b.       get rid of normal amounts of HCO3 into the urine.

          c.       create normal amounts of HCO3 for the body’s needs. 

          d.       reabsorb the usual amount of urea.

 

 

9.       A 32 year old woman presents with hematuria and sudden onset of severe, spasmodic right flank pain. Her diagnosis is most likely                                                                    

          a.       ureteral lithiasis.

          b.       PID.

          c.       pyelonephritis.

          d.       salpingitis.

 

10.     A 32 year old woman presents to her nurse practitioner with vague complaints of bloating, constipation,          and diffuse pelvic pain, onset several months ago. What should the N.P. suspect?      

          a.       Endometriosis.

          b.      Ovarian cancer. 

          c.       AKI.

          d.       Dysmenorrhea.

 

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Readscenario I.  Then decide which of  sentences A – J are correct (there are 5 correct ones) and which are incorrect.  Answer questions 11 & 12 as they apply to scenario I.

 

Scenario I:Ms. Dolores Umbridge is a 63-year-old patient who has been on a nephrotoxic dose of antibiotics.  She develops ATN(acute tubular necrosis) as a result.  Her S&S are as follows:  acute oliguria & generalized edema.  Blood work:  BUN = 27, creatinine = 3.0.   UA: casts are noted. 

 

A.       This patient’s AKI (acute kidney injury) is considered to be in the prerenal AKI category because an acute event likely caused a low BP.

B.       As cells of the tubules die, they slough off into the urinary tubules and are seen as “casts” in the analysis of the urine.

C.       The patient is oliguric because when the kidney is “sick,” the GFR pathologically increases and allows too much urine to be filtered into tubules.

D.      The following mini-concept map explains the patient’s edema:  sick kidneys à diminished ability to decide how much Na+ and H2O should be secreted in the urineà water is pathologically retained à fluid overloadà eventual edema.

E.       As cells of the tubules die, they slough off into the urinary tubules then are reabsorbed into the peritubular capillaries, causing arterial blockages called casts.

F.       The following mini-concept map explains the patient’s edema:  slow, insidious disease process affects kidneys à over time, DCT becomes refractory to aldosteroneà Na+ and H2O are not retained as they should be and instead are  secreted in the urine (water follows sodium)à excess water in urine à fluid overloadà eventual edema.

G.      This patient has a guarded prognosis because few people get better after having a pre-renal AKI, even after appropriate treatment.  

H.      This patient may have a good prognosis because many times people completely recover following appropriate treatment of an AKI.

I.       This patient’s AKI (acute kidney injury) is considered to be in the intrarenal AKI category because an acute event has caused the tubules of the nephrons to become ischemic and malfunction.

J.       The following explains the patient’s azotemia:  in ATN,  tubular cells die and there is diminishing renal function, including the loss of the ability to get rid of wastes.

 

11.     Which one of the following is correct about the patient in the scenario?

          a.       A

          b.       B

          c.       C

          d.       E

 

12.     All of the following are correct EXCEPT:

          a.       G

          b.       H

          c.       I

          d.       D

 

Readscenario II.  Then decide which of  sentences A – K are correct (there are 6 correct ones) and which are incorrect.  Answer questions 13 – 15 as they apply to scenario II.

 

Scenario II:Over a few years, Ms. Umbridgegoes on to develop chronic kidney disease (CKD). HerS&S are numerous, and include edema, SOB, HTN, and pruritis.  Choose the correct statements about the patient’s current status.

 

A.       The edema is caused by the pathological retention of Na & water as the diseased tubules lose the ability to appropriately “choose” what to hold onto & what to get rid of. 

B.       An RN assessing this patient may expect to hear crackles in the lungs due to pulmonary edema related to pathologically increased preload.

C        Assessment findings on this patient may include a BP of 180/110 because renin secretion from the JGA is pathologically decreased.

D.      In CKD the tubules lose the ability to respond appropriately to aldosterone, resulting in a high preload that contributes to the patient’s edema.

E.         Lab results consistent with this patient picture would typically include, for example, a BUN of 29 and creatinine of 1.1.

F.       Urinalysis results consistent with this patient picture may include low specific gravity because the kidneys lose the ability to concentrate urine appropriately.

G.      Because the patient likely has a high BUN, she is considered to be in a state of uremia.

H.      In CKD the tubules lose the ability to respond appropriately to aldosterone, resulting in accumulation of aldosterone in the blood; this is called azotemia.

I.       The nurse taking care of this patient finds her to be confused and is not surprised, since this symptom is sometimes found in uremic patients.

J.       The pruritis is likely due to salt-like deposits of urea on the skin related to the patient’s azotemia.

K.       Uremic encephalopathy may be seen in this patient as a result of osmotic changes that include shift of fluid from brain cells to the hyperosmolar blood.

 

13.     Which one of the following is correct about the patient in the scenario?

          a.       G

          b.       E

          c.       C

          d.       D

 

14.     All of the following are correct EXCEPT:

          a.       A

          b.       B

          c.       C

          d.       I

 

15.     Which one of the following is correct about the patient in the scenario?

            a.       J

          b.       H

          c.       K

          d.       C

 

 

Readscenario III.  Then decide which of  sentences A – I  are correct (there are 4 correct ones) and which are incorrect.  Answer questions 16 -18 as they apply to scenario III.

 

Scenario III:Ms. Umbridge’s CKD will need a certain treatment plan which is described correctly in some of the statements below.

 

A.       Diuretics are not usually given to a CKD patient, since potassium is likely to be urinated out as well, worsening the hypokalemia that is always a danger in patients with CKD. 

B.       A patient with CKD is likely to be malnourished, so a diet high in protein, vitamins, and calcium is crucial. 

C.       Since a CKD patient is almost always in a potentially dangerous state of fluid overload, a diuretic will be given to “mobilize” fluids—get them out of the tissue into the blood, and then help the kidneys to urinate them out of the body. 

D.      Phosphate is often not metabolized properly by diseased kidneys, so phosphate supplements will be important for the nurse to give to the CKD patient.

E.       Calcium supplements will also be important, since diseased kidneys cannot properly activate vitamin D, thus lessening dietary calcium absorption.

F.       A diet low in protein is important so that there will be less urea nitrogen created when the proteins are catabolized in the liver.

G.      The patient will be highly fatigued due to anemia related to less erythropoietin; her nurse will likely need to give her erythropoietin injections.

H.      An RN caring for this patient will need to watch for S&S of “thickened blood” since there will often be an over-abundance of RBCs related to increased erythropoietin secretion.

I.       The nurse caring for this patient will be giving hypotonic IV fluids to counteract the hyperosmolality of the blood.

 

16.     Choose the correct statement about treating this patient in CKD.

          a.       A

          b.       B

          c.       C

          d.       D

 

17.     Choose another correct statement about treating this patient in CKD.

          a.       I

          b.       H

          c.       A

          d.       F

 

18.     J *Dolores Umbridgeis

          a.       an evil professor in the Harry Potter series.

          b.       an evil nursing professor at UTA.

          c.       the competent head nurse on the TV series, ER.

          d.       the evil head nurse in One Flew Over the Cuckoo’s Nest.

*(Google her if you don’t know the answer)

 

19.     A 29-year old woman has dull pain in two separate focal areas of her abdomen that seems to come and go cyclically.  She also complains of occasional dyspareunia.  Her abdomen is tender to palpation in the areas she described.  Which of the following most accurately matches S&S to pathology?

          a.       The cyclical pain is probably related to dysmenorrhea from hormonal malfunction.

b.       Because of monthly retrograde bleeding, there are bits of ectopic endometrium in the abdomen that cause pain.

c.       PID has caused bilateral salpingo-oopheritis.

d.       Endometriosis has caused ectopic areas of cancerous tissue in the abdomen that cause pain on a cyclical basis.

 

20.     Several years later the patient in question 19 has a bowel obstruction and has emergency surgery.  How does this surgical incident relate to the situation above?

          a.       The cancerous tissue spread and invaded the bowel.

          b.       The PID infection spread to the bowels and caused chronic inflammation.

c.       Ectopic endometrial bleeding eventually caused adhesions that obstructed the bowel.

d.       Adhesions from hormonally-triggered amenorrhea eventually caused bowel obstruction.

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