Four patients arrive in the ED. Which patient presentation i… | MyMerci
NCLEX-RN PA
Question

Four patients arrive in the ED. Which patient presentation indicates a hypertensive EMERGENCY (rather than urgency) and requires admission to the ICU for IV antihypertensive titration?

Explanation
Choice 2 has BP > 180/120 PLUS end-organ damage findings (severe headache, vomiting, blurred vision, confusion suggest hypertensive encephalopathy or possible intracerebral hemorrhage). This is hypertensive EMERGENCY requiring ICU admission and IV antihypertensive (e.g., nicardipine, labetalol, clevidipine) titrated to controlled BP reduction (usually no more than 25% in the first hour). Choices 1 and 3 are hypertensive URGENCY (high BP, no end-organ damage) — managed with oral agent restart and outpatient follow-up. Choice 4 is not severe.

In-depth explanation

The single distinguishing feature between emergency and urgency is end-organ damage — encephalopathy, ICH, MI, dissection, AKI, papilledema, pulmonary edema, eclampsia. The number alone does not define emergency. Rapid BP drop in urgency can cause stroke; titrate carefully (no more than 25% reduction in the first hour even in true emergency).

Clinical scenario

The triage nurse evaluates 4 patients with markedly elevated blood pressure. Distinguishing hypertensive emergency (BP > 180/120 with end-organ damage) from urgency (same BP without end-organ damage) drives disposition.

Key concepts

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For study reference only. Always follow current clinical guidelines and your institution’s protocols.