ADULT CCRN CERTIFICATION
MODULE 6
RENAL AND GENITOURINARY
4 PRACTICE TESTS
2024
1. A 65-year-old man with a history of hypertension, diabetes mellitus,
and chronic kidney disease (CKD) stage 3 presents to the
emergency department with dyspnea, orthopnea, and bilateral
crackles on chest auscultation. His blood pressure is 180/100
mmHg, pulse is 110 beats/min, respiratory rate is 28 breaths/min,
and oxygen saturation is 90% on room air. His serum creatinine is
2.5 mg/dL and blood urea nitrogen (BUN) is 50 mg/dL. What is the
most likely diagnosis for this patient?
- A) Acute kidney injury (AKI) due to volume overload
- B) AKI due to contrast-induced nephropathy
- C) AKI due to acute tubular necrosis
- D) CKD exacerbation due to heart failure*
- Rationale: The patient has signs and symptoms of heart failure,
which is a common cause of CKD exacerbation. Heart failure can
lead to reduced renal perfusion, increased venous pressure, and
activation of neurohormonal pathways that worsen renal function.
Volume overload, contrast-induced nephropathy, and acute tubular
necrosis are possible causes of AKI, but they do not explain the
, patient's cardiac findings.
2. A 45-year-old woman with a history of systemic lupus
erythematosus (SLE) and CKD stage 4 is admitted to the intensive
care unit with fever, rash, arthralgia, and hematuria. She has been
taking prednisone and hydroxychloroquine for her SLE. Her serum
creatinine is 3.8 mg/dL and BUN is 60 mg/dL. A urine analysis
shows proteinuria, hematuria, and red blood cell casts. A renal
biopsy reveals diffuse proliferative glomerulonephritis. What is the
most appropriate treatment for this patient?
- A) High-dose corticosteroids and cyclophosphamide*
- B) Low-dose corticosteroids and azathioprine
- C) Angiotensin-converting enzyme (ACE) inhibitors and diuretics
- D) Hemodialysis and plasmapheresis
- Rationale: The patient has lupus nephritis, which is a severe form
of SLE that affects the kidneys. Lupus nephritis can cause rapid
deterioration of renal function and progression to end-stage renal
disease if not treated aggressively. The standard treatment for lupus
nephritis is high-dose corticosteroids and cyclophosphamide, which
are immunosuppressive agents that reduce inflammation and
prevent further damage to the glomeruli. Low-dose corticosteroids
and azathioprine are less effective and may be used for maintenance
therapy after induction with high-dose corticosteroids and
cyclophosphamide. ACE inhibitors and diuretics are supportive
measures that can lower blood pressure and reduce edema, but they
do not address the underlying cause of lupus nephritis.
Hemodialysis and plasmapheresis are reserved for patients with
severe renal failure or life-threatening complications such as
pulmonary hemorrhage or cerebral vasculitis.
3. A 55-year-old man with a history of hypertension, coronary artery
disease, and CKD stage 5 is on maintenance hemodialysis three
times a week. He complains of fatigue, weakness, nausea, vomiting,
and pruritus. His serum calcium is 8.0 mg/dL, phosphorus is 6.5
mg/dL, parathyroid hormone (PTH) is 800 pg/mL, and vitamin D is
10 ng/mL. What is the most likely diagnosis for this patient?
- A) Secondary hyperparathyroidism*
- B) Primary hyperparathyroidism
, - C) Hypoparathyroidism
- D) Pseudohypoparathyroidism
- Rationale: The patient has secondary hyperparathyroidism, which is a common
complication of CKD that results from impaired phosphate excretion, reduced
vitamin D synthesis, and decreased calcium absorption. These factors lead to
hypocalcemia, hyperphosphatemia, and low vitamin D levels, which stimulate PTH
secretion from the parathyroid glands. PTH acts to increase calcium levels by
mobilizing calcium from the bones, increasing calcium reabsorption in the kidneys,
and stimulating vitamin D activation in the kidneys. However, in CKD patients, PTH
becomes less effective due to reduced renal function and receptor resistance.
Therefore, PTH levels continue to rise, causing bone resorption, soft tissue
calcification, and metabolic acidosis. Primary hyperparathyroidism is caused by a
parathyroid adenoma or hyperplasia that secretes PTH autonomously, leading to
hypercalcemia, hypophosphatemia, and low vitamin D levels. Hypoparathyroidism is
caused by a deficiency of PTH, leading to hypocalcemia, hyperphosphatemia, and
high vitamin D levels. Pseudohypoparathyroidism is a rare genetic disorder that
causes resistance to the action of PTH, leading to hypocalcemia, hyperphosphatemia,
and high PTH levels.
Which of the following is a characteristic feature of acute kidney injury
(AKI)?
a) Gradual deterioration of kidney function
b) Sudden onset of kidney dysfunction
c) Irreversible damage to the kidneys
d) Slow progression of symptoms over months
Answer: b) Sudden onset of kidney dysfunction
Rationale: Acute kidney injury is characterized by a rapid decline in
kidney function over a short period, leading to the accumulation of
waste products and imbalances in bodily fluids.
What is the most common cause of acute kidney injury?
a) Hypertension
b) Diabetes mellitus
c) Urinary tract infection
d) Decreased blood flow to the kidneys
Answer: d) Decreased blood flow to the kidneys
Rationale: Reduced blood flow to the kidneys, known as ischemic
injury, is the most common cause of acute kidney injury, leading to
decreased filtration and impaired kidney function.
MODULE 6
RENAL AND GENITOURINARY
4 PRACTICE TESTS
2024
1. A 65-year-old man with a history of hypertension, diabetes mellitus,
and chronic kidney disease (CKD) stage 3 presents to the
emergency department with dyspnea, orthopnea, and bilateral
crackles on chest auscultation. His blood pressure is 180/100
mmHg, pulse is 110 beats/min, respiratory rate is 28 breaths/min,
and oxygen saturation is 90% on room air. His serum creatinine is
2.5 mg/dL and blood urea nitrogen (BUN) is 50 mg/dL. What is the
most likely diagnosis for this patient?
- A) Acute kidney injury (AKI) due to volume overload
- B) AKI due to contrast-induced nephropathy
- C) AKI due to acute tubular necrosis
- D) CKD exacerbation due to heart failure*
- Rationale: The patient has signs and symptoms of heart failure,
which is a common cause of CKD exacerbation. Heart failure can
lead to reduced renal perfusion, increased venous pressure, and
activation of neurohormonal pathways that worsen renal function.
Volume overload, contrast-induced nephropathy, and acute tubular
necrosis are possible causes of AKI, but they do not explain the
, patient's cardiac findings.
2. A 45-year-old woman with a history of systemic lupus
erythematosus (SLE) and CKD stage 4 is admitted to the intensive
care unit with fever, rash, arthralgia, and hematuria. She has been
taking prednisone and hydroxychloroquine for her SLE. Her serum
creatinine is 3.8 mg/dL and BUN is 60 mg/dL. A urine analysis
shows proteinuria, hematuria, and red blood cell casts. A renal
biopsy reveals diffuse proliferative glomerulonephritis. What is the
most appropriate treatment for this patient?
- A) High-dose corticosteroids and cyclophosphamide*
- B) Low-dose corticosteroids and azathioprine
- C) Angiotensin-converting enzyme (ACE) inhibitors and diuretics
- D) Hemodialysis and plasmapheresis
- Rationale: The patient has lupus nephritis, which is a severe form
of SLE that affects the kidneys. Lupus nephritis can cause rapid
deterioration of renal function and progression to end-stage renal
disease if not treated aggressively. The standard treatment for lupus
nephritis is high-dose corticosteroids and cyclophosphamide, which
are immunosuppressive agents that reduce inflammation and
prevent further damage to the glomeruli. Low-dose corticosteroids
and azathioprine are less effective and may be used for maintenance
therapy after induction with high-dose corticosteroids and
cyclophosphamide. ACE inhibitors and diuretics are supportive
measures that can lower blood pressure and reduce edema, but they
do not address the underlying cause of lupus nephritis.
Hemodialysis and plasmapheresis are reserved for patients with
severe renal failure or life-threatening complications such as
pulmonary hemorrhage or cerebral vasculitis.
3. A 55-year-old man with a history of hypertension, coronary artery
disease, and CKD stage 5 is on maintenance hemodialysis three
times a week. He complains of fatigue, weakness, nausea, vomiting,
and pruritus. His serum calcium is 8.0 mg/dL, phosphorus is 6.5
mg/dL, parathyroid hormone (PTH) is 800 pg/mL, and vitamin D is
10 ng/mL. What is the most likely diagnosis for this patient?
- A) Secondary hyperparathyroidism*
- B) Primary hyperparathyroidism
, - C) Hypoparathyroidism
- D) Pseudohypoparathyroidism
- Rationale: The patient has secondary hyperparathyroidism, which is a common
complication of CKD that results from impaired phosphate excretion, reduced
vitamin D synthesis, and decreased calcium absorption. These factors lead to
hypocalcemia, hyperphosphatemia, and low vitamin D levels, which stimulate PTH
secretion from the parathyroid glands. PTH acts to increase calcium levels by
mobilizing calcium from the bones, increasing calcium reabsorption in the kidneys,
and stimulating vitamin D activation in the kidneys. However, in CKD patients, PTH
becomes less effective due to reduced renal function and receptor resistance.
Therefore, PTH levels continue to rise, causing bone resorption, soft tissue
calcification, and metabolic acidosis. Primary hyperparathyroidism is caused by a
parathyroid adenoma or hyperplasia that secretes PTH autonomously, leading to
hypercalcemia, hypophosphatemia, and low vitamin D levels. Hypoparathyroidism is
caused by a deficiency of PTH, leading to hypocalcemia, hyperphosphatemia, and
high vitamin D levels. Pseudohypoparathyroidism is a rare genetic disorder that
causes resistance to the action of PTH, leading to hypocalcemia, hyperphosphatemia,
and high PTH levels.
Which of the following is a characteristic feature of acute kidney injury
(AKI)?
a) Gradual deterioration of kidney function
b) Sudden onset of kidney dysfunction
c) Irreversible damage to the kidneys
d) Slow progression of symptoms over months
Answer: b) Sudden onset of kidney dysfunction
Rationale: Acute kidney injury is characterized by a rapid decline in
kidney function over a short period, leading to the accumulation of
waste products and imbalances in bodily fluids.
What is the most common cause of acute kidney injury?
a) Hypertension
b) Diabetes mellitus
c) Urinary tract infection
d) Decreased blood flow to the kidneys
Answer: d) Decreased blood flow to the kidneys
Rationale: Reduced blood flow to the kidneys, known as ischemic
injury, is the most common cause of acute kidney injury, leading to
decreased filtration and impaired kidney function.
