16. The nursing priorities for the care of a client with acute glomerulonephritis are:
Select all that apply.
16. The nursing priorities for the care of a client with acute glomerulonephritis are:
Select all that apply.
. Performing range of motion.
. Encouraging a diet high in protein.
. Maintaining strict I&O.
. Teaching intermittent self-catheterization for urine retention.
. Monitoring daily weight.
. Recording BP at least q4h.
Test-Taking Tip
Choose the answers that most directly relate to monitoring renal function.
Content Area: Adult Health, Renal; Integrated Process: Nursing Process, Planning; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems
. . .
Answer 1 is incorrect because the client is not necessarily on prolonged bedrest. Immobility is not the priority. Bedrest is indicated until hypertension is controlled. Answer 2 is incorrect because protein needs to be limited due to proteinuria, which is present with the disease. Carbohydrates are the source of energy. Answer 3 is correct because acute glomerulonephritis (AGN) decreases glomerular function. Fluid is restricted during the edematous phase. There is a risk of renal failure as a result of the inflammation ("itis"). Answer 4 is incorrect because the problem is not retention but the potential for renal failure and inadequate urine proteinuria. The disease progresses from edema to diuresis. Answer 5 is correct because the edematous phase of AGN lasts from 4 to 10 days. Daily weight is the best indicator of fluid changes. Answer 6 is correct because hypertension occurs with AGN. Headache is common. Antihypertensives will be ordered and BP needs to be recorded q4h.