Chapter 38: Alterations of Renal and Urinary Tract Function

MULTIPLE CHOICE
1. How does progressive nephrons injury affect angiotensin II activity?
a. Angiotensin II activity is decreased.
b. It is elevated.
c. Angiotensin II activity is totally suppressed.
d. It is not affected.
ANS: B

Angiotensin II activity is elevated with progressive nephron injury. This selection is the only
accurate identification of the effect of progressive nephron injury on angiotensin II activity.
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REF: Page 1364 | Page 1366

2. Which mineral accounts for the most common type of renal stone?
a. Magnesium-ammonium-phosphate
c. Calcium oxalate
b. Uric acid
d. Magnesium phosphate
ANS: C

Calcium stones (calcium phosphate or calcium oxalate) account for 70% to 80% of all stones
requiring treatment.
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REF: Page 1343

3. Regarding the formation of renal calculi, what function does pyrophosphate, potassium

citrate, and magnesium perform?

a. They inhibit crystal growth.
b. Pyrophosphate, potassium citrate, and magnesium stimulate the supersaturation of

salt.
c. They facilitate the precipitation of salts from a liquid to a solid state.
d. Pyrophosphate, potassium citrate, and magnesium enhance crystallization of salt

crystals to form stones.

ANS: A

Stone or crystal growth inhibiting substances, including potassium citrate, pyrophosphate, and
magnesium, are capable of crystal growth inhibition. They are not capable of the functions
stated by the other options.
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REF: Page 1343

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
ANS: B

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.
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REF: Page 1343

5. Detrusor hyperreflexia develops from neurologic disorders that originate where?

a. Spinal cord between C2 and S1
c. Above the pontine micturition center
b. Spinal cord between S2 and S4
d. Below the cauda equina
ANS: C

Neurologic disorders that develop above the pontine micturition center result in detrusor
hyperreflexia, also known as an uninhibited or reflex bladder. This selection is the only option
responsible for detrusor hyperreflexia.
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REF: Page 1345

6. Considering the innervation of the circular muscles of the bladder neck, which classification

of drug is used to treat bladder neck obstruction?

a. -Adrenergic blocking medications
c. Parasympathomimetic medications
b. -Adrenergic blocking medications
d. Anticholinesterase medications
ANS: B

Because the bladder neck consists of circular smooth muscle with adrenergic innervation,
detrusor sphincter dyssynergia may be managed by -adrenergic blocking (antimuscarinic)
medications. This selection is the only option capable of this specific function.
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REF: Page 1346

7. Renal cell carcinoma, classified as clear cell tumors, arises from epithelial cells in which

structure?
a. Proximal tubule
b. Distal tubule

c. Nephron
d. Glomerulus

ANS: A

Renal cell carcinoma, classified as clear cell tumors according to cell type and extent of
metastasis, arises from the proximal tubular epithelium. These tumors are not associated with
the other options.
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REF: Page 1347

8. 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
ANS: C

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. This
process is not associated with the other options.

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REF: Page 1348

9. What is the most common cause of uncomplicated urinary tract infections?

a. Staphylococcus
c. Proteus
b. Klebsiella
d. Escherichia coli
ANS: D

The most common infecting microorganisms are uropathic strains of E. coli (80% to 85%).
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REF: Page 1350

10. Which differentiating sign is required to make the diagnosis of pyelonephritis from that of

cystitis?
Difficulty starting the stream of urine
Spasmodic pain that radiates to the groin
Increased glomerular filtration rate
Urinalysis confirmation of white blood cell casts

a.
b.
c.
d.

ANS: D

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. White blood cell casts indicate pyelonephritis, but they are not always
present in the urine. This selection is the only option that is considered a required sign of
pyelonephritis.
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REF: Pages 1351-1352

11. Considering host defense mechanisms, which element in the urine is bacteriostatic?
a. High pH (alkaline urine)
c. High glucose
b. High urea
d. High calcium
ANS: B

Dilute urine washes out bacteria, and urine with higher urea concentrations (high osmolarity)
is more bacteriostatic.
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REF: Page 1350

12. Which clinical manifestations of a urinary tract infection may be demonstrated in an 85-year-

old individual?
a. Confusion and poorly localized abdominal discomfort
b. Dysuria, frequency, and suprapubic pain
c. Hematuria and flank pain
d. Pyuria, urgency, and frequency
ANS: A

Older adults with cystitis may demonstrate confusion or vague abdominal discomfort or
otherwise be asymptomatic.
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REF: Page 1351

13. Pyelonephritis is usually caused by which type of organism?

a. Bacteria
b. Fungi

c. Viruses
d. Parasites

ANS: A

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

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REF: Pages 1351-1352

14. Which abnormal laboratory value is found in glomerular disorders?

a. Elevated creatinine concentration
c. Elevated immunoglobulin A (IgA)
b. Low blood urea nitrogen (BUN)
d. Low serum complement
ANS: A

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.
Glomerular disorders are not associated with the other options.
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REF: Page 1357

15. Which glomerular lesion is characterized by thickening of the glomerular capillary wall with

immune deposition of immunoglobulin G (IgG) and C3?

c. Mesangial
d. Crescentic

a. Proliferative
b. Membranous
ANS: B

The thickening of the glomerular capillary wall characterizes only membranous lesions.
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REF: Page 1355 | Table 38-6

16. Goodpasture syndrome is an example of which of the following?

a. Antiglomerular basement membrane disease
b. Acute glomerulonephritis
c. Chronic glomerulonephritis
d. Immunoglobulin A (IgA) nephropathy
ANS: A

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.
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REF: Page 1355 | Table 38-5

17. 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. These data suggest the presence of
which disorder?
a. Cystitis
c. Glomerulonephritis
b. Chronic pyelonephritis
d. Nephrotic syndrome
ANS: C

The data suggest the patient has the disorder known as 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. These
symptoms do not support the diagnosis of the other options.
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REF: Page 1357

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

Symptoms of nephrotic syndrome include edema, hyperlipidemia, lipiduria, vitamin D

deficiency, and hypothyroidism. These symptoms do not support the other options.
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REF: Page 1359

19. Which antibiotics are considered major culprits in causing nephrotoxic acute tubular

necrosis (ATN)?
a. Penicillin and ampicillin
b. Vancomycin and bacitracin

c. Gentamicin and tobramycin

d. Cefazolin and cefepime

ANS: C

Although numerous antibiotics can produce nephrotoxic ATN, the aminoglycosides

(gentamicin, tobramycin) are the major culprits.
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REF: Page 1361

20. 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
ANS: A

Urine sodium >30 mEq/L is the only option indicative of ATN.

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REF: Page 1363 | Table 38-11

21. 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.

ANS: B

This selection is the only option that accurately describes glucose metabolism, causing
potassium to move to the intracellular fluid; insulin infusions therefore can be effective in
shifting potassium from the extracellular to intracellular space, along with the transport of
glucose.
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REF: Page 1363

22. 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

ANS: C

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

filtration.
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REF: Page 1366

23. Which statement is false concerning the skeletal alterations caused by chronic renal failure

when the glomerular filtration rate (GFR) declines to 25% of normal?

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 synthesis of 1,25-vitamin D3, which impairs the effectiveness of calcium and
phosphate resorption from bone by parathyroid hormone, is impaired.
ANS: B

Bone and skeletal changes develop with alterations in calcium and phosphate metabolism (see
Table 38-16). 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 options are true.
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REF: Page 1368 | Table 38-16

24. Anemia of chronic renal failure can be successfully treated with which element?
a. Intrinsic factor
c. Vitamin D
b. Vitamin B12
d. Erythropoietin
ANS: D

Anemia of chronic renal failure can be successfully treated with erythropoietin. Reduced
erythropoietin secretion and reduced red cell production are evident in anemia resulting from
chronic renal failure. The other options are not relevant to this condition.
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REF: Page 1365 | Page 1369 | Table 38-13

25. 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

ANS: B

These processes cause the contralateral (unobstructed) kidney to increase the size of
individual glomeruli and tubules. The changes described by the other options are not correct.
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REF: Page 1342

26. 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
c. Necrotic bladder
b. Obstructed bladder
d. Retrograde bladder
ANS: A

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 (see Figure 38-3). None of the other options correctly identify the
described condition.
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REF: Pages 1344-1345

MULTIPLE RESPONSE
27. In glomerulonephritis, what damages the epithelial cells resulting in proteinuria? (Select all

that apply.)
Ischemia
Lysosomal enzymes
Compression from edema
Activated complement
Altered membrane permeability

a.
b.
c.
d.
e.

ANS: D, E

Activated complement, inflammatory cytokines, oxidants, proteases, and growth factors attack
epithelial cells, alter membrane permeability, and cause proteinuria. None of the other options
are responsible for this process.
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REF: Pages 1353-1357

28. Which statements are true concerning struvite stones? (Select all that apply.)
a. They are more common in women than in men.
b. Struvite stones are associated with chronic laxative use in women.
c. They grow large and branch into a staghorn configuration in renal pelvis and

calyces.
d. Struvite stones are closely associated with urinary tract infections caused by urease-

producing bacteria, such as Pseudomonas.

e. They are more common in men than in women.
ANS: A, C, D

Women are at greater risk for developing struvite stones, but the risk is greater because
women have an increased incidence of urinary tract infections not because of chronic laxative
use. Such stones grow large and branch into a staghorn configuration and are associated with
Pseudomonas.

PTS: 1

REF: Pages 1343-1344

29. Which statements are true regarding renal colic? (Select all that apply.)
a. Renal colic results in mild-to-moderate pain.
b. Pain originates in the flank area.
c. Renal colic indicates the presence of renal stones.
d. Pain radiated to the groin.
e. Renal colic indicates obstruction of the renal pelvis or proximal ureter.
ANS: B, C, D, E

Renal colic is described as moderate-to-severe pain often originating in the flank and radiating
to the groin. It usually indicates obstruction by renal stones of the renal pelvis or proximal
ureter.
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REF: Page 1344

30. Which conditions related to the bladder would result from the effects of lesions of the sacral

segments below S1? (Select all that apply.)

Frequency
Urge incontinence
Bladder distension
Urgency
Urinary retention

a.
b.
c.
d.
e.

ANS: C, E

Lesions that involve the sacral micturition center (below S1; may also be termed cauda
equina syndrome) or peripheral nerve lesions result in detrusor areflexia (acontractile
detrusor), a lower motor neuron disorder. The result is an acontractile detrusor or atonic
bladder with retention of urine and distention. The other options are associated with
neurologic lesions that occur between C2 and S1
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REF: Page 1345

31. What are considered risk factors for developing bladder and kidney cancers? (Select all that

apply.)
Cigarette smoking
Hypertension
Exposure to aniline dyes
Below normal body weight
Male gender

a.
b.
c.
d.
e.

ANS: A, B, C

Risk factors for renal cancer include cigarette smoking, obesity, and hypertension. The risk of
primary bladder cancer is greater among people who smoke or those who are exposed to
metabolites of aniline dyes or other aromatic amines or chemicals and with heavy
consumption of phenacetin. Gender is not a recognized risk factor.
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REF: Pages 1347-1349

32. Which renal disorders are considered causes of intrarenal renal failure? (Select all that apply.)
a. Acute glomerulonephritis

b.
c.
d.
e.

Allograft rejection
Tumors
Acute tubular necrosis (ATN)
Prostatic hypertrophy

ANS: A, B, C, D

Intrarenal (intrinsic) acute kidney injury (AKI) may result from ischemic ATN, nephrotoxic
ATN, acute glomerulonephritis, vascular disease, allograft rejection, or interstitial disease
(drug allergy, infection, tumor growth). Prostatic hypertrophy is not associated with intrarenal
renal failure.
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REF: Pages 1360-1361

33. Prerenal injury from poor perfusion can result from which condition? (Select all that apply.)
a. Bilateral ureteral obstruction
b. Renal vasoconstriction
c. Renal artery thrombosis
d. Hemorrhage
e. Hypotension
ANS: B, C, D, E

Poor perfusion can result from renal artery thrombosis, hypotension related to hypovolemia
(dehydration, diarrhea, fluid shifts) or hemorrhage, renal vasoconstriction and alterations in
renal regional blood flow, microthrombi, or kidney edema that restricts arterial blood flow.
Bilateral ureteral obstruction is not associated with prerenal injuries.
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REF: Page 1360

MATCHING

Match the predisposing factors causing pyelonephritis to the pathology mechanism.

______ A. Kidney stones
______ B. Vesicoureteral reflux
______ C. Pregnancy
______ D. Neurogenic bladder
______ E. Female sexual trauma
34. Movement of organisms from the urethra into the bladder with infection and retrograde spread
35.
36.
37.
38.

to the kidney
Dilation and relaxation of the ureter with hydroureter and hydronephrosis
Impairment to the bladder, interfering with normal bladder contraction and causing residual
urine and ascending infection
Obstruction and stasis of urine, contributing to bacteremia and hydronephrosis; irritation of
epithelial lining with entrapment of bacteria
Chronic reflux of urine up the ureter and into the kidney during micturition, contributing to
bacterial infection

34. ANS: E
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REF: Page 1352 | Table 38-4
MSC: Female sexual trauma can result from the movement of organisms from the urethra into the
bladder with infection and retrograde spread to the kidney.
35. ANS: C
PTS: 1
REF: Page 1352 | Table 38-4

MSC: Pregnancy causes the dilation and relaxation of the ureter with hydroureter and hydronephrosis.
36. ANS: D
PTS: 1
REF: Page 1352 | Table 38-4
MSC: Neurogenic bladder, caused by neurologic impairment, results in the interference of normal
bladder and urethral sphincter contraction and causes residual urine and ascending infection.
37. ANS: A
PTS: 1
REF: Page 1352 | Table 38-4
MSC: Kidney stones result in the obstruction and stasis of urine, contributing to bacteriuria and
hydronephrosis and causing irritation of epithelial lining with entrapment of bacteria.
38. ANS: B
PTS: 1
REF: Page 1352 | Table 38-4
MSC: Vesicoureteral reflux results in the chronic reflux of urine up the ureter and into the kidney
during micturition, contributing to bacterial infection.