Chapter 39

Question 1

How does progressive nephron injury affect angiotensin II activity?
a. Angiotensin II activity is decreased.
b. Angiotensin II activity is elevated.
c. Angiotensin II activity is totally suppressed.
d. Angiotensin II activity is not affected.

Answer 1

b. Angiotensin II activity is elevated.

Angiotensin II activity is elevated with progressive nephron injury. Angiotensin II promotes
glomerular hypertension and hyperfiltration caused by efferent arteriolar vasoconstriction and
also promotes systemic hypertension. The chronically high intraglomerular pressure increases
glomerular capillary permeability, contributing to proteinuria. Angiotensin II also may promote
the activity of inflammatory cells and growth factors that participate in tubulointerstitial fibrosis
and scarring.

Question 2

A patient has been diagnosed with a renal stone. Based on knowledge of common stone types,
what self-care measure does the healthcare professional plan to teach the patient when stone
analysis has returned?
a. Increase water intake.
b. Decrease soda intake.
c. Restrict animal protein in the diet.
d. Ingest 1000 mg of calcium a day.

Answer 2

d. Ingest 1000 mg of calcium a day.

Calcium stones (calcium phosphate or calcium oxalate) account for 70% to 80% of all stones
requiring treatment. While all choices are appropriate for self-care in the patient with kidney
stones, maintaining a calcium intake of 1000 to 1200 mg/day is a specific preventative measure
for calcium stones.

Question 3

The student asks the professor to explain the role of pyrophosphate, potassium citrate, and
magnesium in the formation of kidney stones. What response by the professor is best?
a. They inhibit crystal growth.
b. They stimulate the supersaturation of salt.
c. They facilitate the precipitation of salts.
d. They enhance crystallization of salt crystals.

Answer 3

a. They inhibit crystal growth.

Stone or crystal growth inhibiting substances, including potassium citrate, pyrophosphate, and
magnesium, are capable of crystal growth inhibition. They do not stimulate supersaturation of
salt, facilitate the precipitation of salts, or enhance crystallization of salts.

Question 4

Hypercalciuria is primarily attributable to which alteration?
a. Defective renal calcium reabsorption
b. Intestinal hyperabsorption of dietary calcium
c. Bone demineralization caused by prolonged immobilization
d. Hyperparathyroidism

Answer 4

b. Intestinal hyperabsorption of dietary calcium

Hypercalciuria is usually attributable to intestinal hyperabsorption of dietary calcium and less
commonly to a defect in renal calcium reabsorption. Hyperparathyroidism and bone
demineralization associated with prolonged immobilization are also known to cause
hypercalciuria but too a much lesser degree.

Question 5

Detrusor hyperreflexia develops from neurologic disorders that originate where?
a. Spinal cord between C2 and C4
b. Spinal cord between S2 and S4
c. Above the pontine micturition center
d. Below the cauda equina

Answer 5

c. Above the pontine micturition center

Neurologic disorders that develop above the pontine micturition center result in detrusor
hyperreflexia, also known as an uninhibited or reflex bladder.

Question 6

A patient has overactive bladder syndrome. Which classification of drug does the healthcare
professional plan to teach the patient about?
a. beta-Adrenergic blocking medications
b. alpha-Adrenergic blocking medications
c. Parasympathomimetic medications
d. Anticholinesterase medications

Answer 6

b. alpha-Adrenergic blocking medications

Because the bladder neck consists of circular smooth muscle with adrenergic innervation,
detrusor sphincter dyssynergia may be managed by -adrenergic blocking (antimuscarinic)
medications. The other medications would not be of benefit in this situation.

Question 7

Bladder cancer is associated with the gene mutation of which gene?
a. c-erbB2
b. Human epidermal growth factor receptor 2 (HER2)
c. TP53
d. myc

Answer 7

c. TP53

Oncogenes of the ras gene family and tumor-suppressor genes including TP53 mutations and the
inactivation of the retinoblastoma gene (pRb) are implicated in bladder cancer. The c-erbB2 gene
is associated with breast cancer as is HER2. The myc gene codes for a transcription factor that
plays a role in cellular life cycle events.

Question 8

A female patient has been diagnosed with an uncomplicated urinary tract infection. What self-
care measure does the healthcare provider teach the patient that is specific to this type of

infection?
a. Drink at least eight glasses of water a day.
b. Take medication if you have a fever.
c. Rest as much as you can in the next few days.
d. After using the bathroom, wipe from front to back.

Answer 8

d. After using the bathroom, wipe from front to back.

The most common infecting microorganisms are E. coli (80% to 85%) which is transmitted from
the gut where it is a normal resident. Women should be taught to wipe from front to back after
using the bathroom to avoid contamination of the urinary meatus with fecal material containing
E. coli. The other options are appropriate for any type of infection.

Question 9

A healthcare professional is assessing a patient who could have either pyelonephritis or cystitis.
Which differentiating sign would assist the professional in making this diagnosis?
a. Difficulty starting the stream of urine
b. Spasmodic pain that radiates to the groin
c. Increased glomerular filtration rate
d. Urinalysis confirmation of white blood cell casts

Answer 9

d. Urinalysis confirmation of white blood cell casts

Clinical assessment alone is difficult to differentiate the symptoms of cystitis from those of
pyelonephritis. Urine culture, urinalysis, and clinical signs and symptoms establish the specific
diagnosis. When present, white blood cell casts indicate pyelonephritis. Difficulty starting the
urine stream could indicate prostate enlargement. Neither disorder has spasmodic pain that
radiates to the groin; this would be indicative of a kidney stone. Increased GFR would not be
seen in an infectious disorder.

Question 10

An 85-year-old person has a urinary tract infection. What clinical manifestation does the
healthcare professional expect to see in this person?
a. Confusion and poorly localized abdominal discomfort
b. Dysuria, frequency, and suprapubic pain
c. Hematuria and flank pain
d. Pyuria, urgency, and frequency

Answer 10

a. Confusion and poorly localized abdominal discomfort

Older adults with cystitis may demonstrate confusion or vague abdominal discomfort or
otherwise be asymptomatic.

Question 11

Pyelonephritis is usually caused by which type of organism?
a. Bacteria
b. Fungi
c. Viruses
d. Parasites

Answer 11

a. Bacteria

Pyelonephritis is usually caused by the bacteria Escherichia coli, Proteus, or Pseudomonas.

Question 12

Which abnormal laboratory value is found in glomerular disorders?
a. Elevated creatinine concentration
b. Low blood urea nitrogen (BUN)
c. Elevated immunoglobulin A (IgA)
d. Low serum complement

Answer 12

a. Elevated creatinine concentration

Elevated creatinine concentration is an abnormal laboratory value found in glomerular disorders.
Reduced glomerular filtration rate during glomerular disease is evidenced by elevated plasma
urea, creatinine concentration, or reduced renal creatinine clearance. Many factors can lead to an
elevation in BUN such as dehydration or poor perfusion, in addition to kidney disease. Elevated
IgA levels are associated with Berger disease. Low serum complement levels would affect
immune functioning.

Question 13

Which glomerular lesion is characterized by thickening of the glomerular capillary wall with
immune deposition of immunoglobulin G (IgG) and C3?
a. Proliferative
b. Membranous
c. Mesangial
d. Crescentic

Answer 13

b. Membranous

The thickening of the glomerular capillary wall characterizes only membranous lesions.

Question 14

Goodpasture syndrome is an example of which of these?
a. Antiglomerular basement membrane disease
b. Acute glomerulonephritis
c. Chronic glomerulonephritis
d. Immunoglobulin A (IgA) nephropathy

Answer 14

a. Antiglomerular basement membrane disease

Antiglomerular basement membrane disease (Goodpasture syndrome) is associated with
immunoglobulin G (IgG) antibody formation against pulmonary capillary and glomerular
basement membranes. Goodpasture syndrome is not an example of any of the other options.

Question 15

A patient exhibits symptoms including hematuria with red blood cell casts and proteinuria
exceeding 3 to 5 g/day, with albumin as the major protein. What diagnostic test or treatment
regime does the healthcare professional educate the patient on?
a. Intravenous pyelogram
b. Oral antibiotics
c. Renal biopsy
d. Cyclophosphamide

Answer 15

c. Renal biopsy

The data suggest the patient has glomerulonephritis. Two major changes distinctive of more
severe glomerulonephritis are (1) hematuria with red blood cell casts and (2) proteinuria
exceeding 3 to 5 g/day with albumin as the major protein. There are several types of this disorder
and treatment is specific to individual types. The patient needs a renal biopsy to determine
appropriate treatment. A pyelogram would help identify kidney stones. Oral antibiotics would be
used if there is an infection. Cyclophosphamide can be used in glomerulonephritis that is
unresponsive to corticosteroids.

Question 16

Hypothyroidism, edema, hyperlipidemia, and lipiduria characterize which kidney disorder?
a. Nephrotic syndrome
b. Acute glomerulonephritis
c. Chronic glomerulonephritis
d. Pyelonephritis

Answer 16

a. Nephrotic syndrome

Symptoms of nephrotic syndrome include edema, hyperlipidemia, lipiduria, vitamin D
deficiency, and hypothyroidism.

Question 17

A patient who has a history of mildly decreased renal function is admitted to the hospital for IV
antibiotics. Which antibiotics would the healthcare professional avoid in this patient?
a. Penicillin and ampicillin
b. Vancomycin and bacitracin
c. Gentamicin and tobramycin
d. Cefazolin and cefepime

Answer 17

c. Gentamicin and tobramycin

Although numerous antibiotics can produce nephrotoxic ATN, the aminoglycosides (gentamicin,
tobramycin) are the major culprits. The healthcare professional would avoid their use in this
patient if at all possible.

Question 18

Which urine characteristics are indicative of acute tubular necrosis (ATN) caused by intrinsic
(intrarenal) failure?
a. Urine sodium >30 mEq/L
b. Urine osmolality >500 mOsm
c. Fractional excretion of sodium (FENa) <1%
d. Urine sediment has no cells, some hyaline casts

Answer 18

a. Urine sodium >30 mEq/L

Urine sodium >30 mEq/L is the only option indicative of ATN. The other findings are associated
with prerenal kidney injury.

Question 19

How are glucose and insulin used to treat hyperkalemia associated with acute renal failure?
a. Glucose has an osmotic effect, which attracts water and sodium, resulting in more
dilute blood and a lower potassium concentration.
b. When insulin transports glucose into the cell, it also carries potassium with it.
c. Potassium attaches to receptors on the cell membrane of glucose and is carried into
the cell.
d. Increasing insulin causes ketoacidosis, which causes potassium to move into the
cell in exchange for hydrogen.

Answer 19

b. When insulin transports glucose into the cell, it also carries potassium with it.

In severe hyperkalemia, potassium can be driven temporarily back into the cell with insulin.
Glucose will also move into the cell. The glucose metabolism helps drive the potassium
movement. Glucose is also given to prevent the patient from developing hypoglycemia.

Question 20

Creatinine is primarily excreted by glomerular filtration after being constantly released from
what type of tissue?
a. Nervous system
b. Kidneys
c. Muscle
d. Liver

Answer 20

c. Muscle

Creatinine is constantly released from muscle tissue to be excreted by glomerular filtration.

Question 21

A professor has taught a student about skeletal alterations seen in chronic kidney disease. Which
statement by the student indicates the professor needs to give more information?
a. Parathyroid hormone is no longer effective in maintaining serum phosphate levels.
b. The parathyroid gland is no longer able to secrete sufficient parathyroid hormone.
c. The synthesis of 1,25-vitamin D3, which reduces intestinal absorption of calcium,
is impaired.
d. The effectiveness of calcium and phosphate resorption from bone is impaired.

Answer 21

b. The parathyroid gland is no longer able to secrete sufficient parathyroid hormone.

Bone and skeletal changes develop with alterations in calcium and phosphate metabolism. These
changes begin when the GFR decreases to 25% or less. The combined effect of
hyperparathyroidism and vitamin D deficiency can result in renal osteodystrophies (e.g.,
osteomalacia, osteitis fibrosa with increased risk for fractures). Other consequences of secondary
hyperparathyroidism include soft tissue and vascular calcification, cardiovascular disease, and,
less commonly, calcific uremic arteriolopathy. The other statements are true.

Question 22

A patient who has chronic kidney disease has hemoglobin of 7.2 mg/dL. What treatment does the
healthcare professional prepare the patient for?
a. Intrinsic factor
b. Vitamin B12
c. Vitamin D
d. Erythropoietin

Answer 22

d. Erythropoietin

Anemia of chronic kidney disease can be successfully treated with erythropoietin. Reduced
erythropoietin secretion and reduced red cell production are evident in anemia resulting from
chronic kidney disease. Intrinsic factor is needed for the absorption of vitamin B12. Vitamin D is
important for calcium absorption.

Question 23

When the right kidney is obstructed, how will the glomeruli and tubules in the left kidney
compensate?
a. Increase in number
b. Increase in size
c. Develop collateral circulation
d. Increase speed of production

Answer 23

b. Increase in size

These processes cause the contralateral (unobstructed) kidney to increase the size of individual
glomeruli and tubules. They do not increase in number, develop collateral circulation, or get
produced more quickly.

Question 24

What medical term is used to identify a functional urinary tract obstruction caused by an
interruption of the nerve supply to the bladder?

a. Neurogenic bladder
b. Obstructed bladder
c. Necrotic bladder
d. Retrograde bladder

Answer 24

a. Neurogenic bladder

Neurogenic bladder is a general term for bladder dysfunction caused by neurologic disorders.
The types of dysfunction are related to the sites in the nervous system that control sensory and
motor bladder function. None of the other options correctly identify the described condition.