A 55-year-old patient with a history of chronic kidney disease presents to the emergency department with a blood pressure of 230/125 mmHg, severe headache, and vomiting. The patient reports non-compliance with dialysis. What is the nurse's priority action?

A patient with chronic kidney disease (CKD) who has missed dialysis presents with a blood pressure of 230/125 mmHg, severe headache, and vomiting. This presentation is a classic hypertensive emergency, a life-threatening condition characterized by severely elevated blood pressure with evidence of acute, ongoing target-organ damage. In this case, the neurological symptoms (severe headache, vomiting) strongly suggest cerebral edema or impending hypertensive encephalopathy. The non-compliance with dialysis is a critical precipitating factor, as fluid overload and uremic toxin accumulation directly contribute to uncontrolled hypertension in CKD patients. Research identifies non-adherence to treatment as a key determinant of hypertensive crisis, reinforcing the link between this patient's history and the current emergency ^[1].

The nurse's priority is to initiate continuous cardiac monitoring and prepare for controlled blood pressure reduction. The goal in a hypertensive emergency is not to normalize blood pressure rapidly, but to reduce mean arterial pressure by no more than 25% within the first hour. A precipitous drop in pressure can lead to cerebral, myocardial, or renal hypoperfusion, causing ischemic stroke, myocardial infarction, or acute kidney injury. Continuous monitoring allows for the titration of intravenous antihypertensive agents, such as nicardipine or clevidipine, to achieve a safe, gradual reduction. This approach directly addresses the life-threatening target-organ damage while preventing iatrogenic harm, aligning with the urgent medical intervention required for hypertensive crisis ^[1].

• Option 1: Administer sublingual nitroglycerin immediately. Sublingual nitroglycerin causes rapid, unpredictable, and often profound vasodilation. This can lead to a dangerous, uncontrolled drop in blood pressure, potentially causing a stroke or myocardial infarction from hypoperfusion. It is not a first-line agent for controlled blood pressure reduction in hypertensive emergencies.


• Option 2: Place the patient in Trendelenburg position. This position elevates the lower body above the head, which would increase intracranial pressure and worsen cerebral edema in a patient already exhibiting signs of hypertensive encephalopathy. This action is contraindicated.


• Option 4: Give a bolus of normal saline before antihypertensive therapy. This patient's hypertension is primarily driven by fluid overload from missed dialysis. Administering a fluid bolus would exacerbate volume overload, potentially precipitating acute pulmonary edema and worsening heart failure. Fluid resuscitation is reserved for cases where hypoperfusion is due to volume depletion, not fluid excess.