# A 48-year-old patient presents to the emergency department with a blood pressure of 230/125 mmHg, severe headache, blurred vision, and confusion. The patient reports chest pain and shortness of breath. Which nursing action should be the HIGHEST priority?

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## 문제

A 48-year-old patient presents to the emergency department with a blood pressure of 230/125 mmHg, severe headache, blurred vision, and confusion. The patient reports chest pain and shortness of breath. Which nursing action should be the HIGHEST priority?

## 보기

1. Administer sublingual nitroglycerin immediately
2. Obtain a 12-lead ECG to assess for myocardial infarction
3. Start an IV line and prepare for antihypertensive medication administration
4. Assess neurological status and monitor for signs of increased intracranial pressure **✔ 정답**

**정답: 4**

## 해설

In hypertensive crisis with neurological symptoms, assessing neurological status is highest priority to detect cerebral complications. Other actions are important but secondary.

## 심화 해설

Clinical Context and Initial Triage

This patient presents with a blood pressure of 230/125 mmHg, severe headache, blurred vision, and confusion. This clinical picture is a hypertensive emergency with clear neurological manifestations, highly suggestive of posterior reversible encephalopathy syndrome (PRES) or a hemorrhagic stroke. The presence of chest pain and shortness of breath indicates concurrent acute target-organ damage in the cardiovascular system, but the altered mental status and visual disturbances signal that the brain is the organ under the most immediate and severe threat. In neurologic emergencies, elevated blood pressure is a significant prognostic factor, and the primary goal is to balance the urgent need to reduce pressure against the risk of causing cerebral hypoperfusion [1].

Rationale for Prioritizing Neurological Assessment

Before administering any intervention that will drastically lower systemic blood pressure, the nurse must establish a baseline neurological status. This is the highest priority action because a rapid, uncontrolled drop in blood pressure can reduce cerebral perfusion pressure below the threshold needed to maintain adequate brain oxygenation, potentially converting an ischemic penumbra into an infarct or worsening cerebral edema in PRES. The assessment allows the nurse to detect focal deficits, changes in pupil reactivity, or a deteriorating level of consciousness that would indicate increased intracranial pressure (ICP). In the context of the provided evidence, effective management hinges on this initial evaluation to guide the speed and target of antihypertensive therapy, ensuring that the intervention does not cause more harm than the disease itself [1].

Analysis of Incorrect Options

- Option 1 (Administer sublingual nitroglycerin immediately): This is an unsafe and uncontrolled method for managing a hypertensive emergency. Sublingual nitroglycerin causes a rapid, unpredictable drop in blood pressure, which can precipitate cerebral ischemia or steal phenomena in patients with compromised cerebral autoregulation. The priority is a controlled, titratable reduction in blood pressure using intravenous agents, not a precipitous drop [1].

- Option 2 (Obtain a 12-lead ECG to assess for myocardial infarction): While the patient’s chest pain and dyspnea warrant a cardiac evaluation, this is a secondary priority. The neurological symptoms (confusion, visual changes) indicate an immediate threat to the central nervous system. A 12-lead ECG is a diagnostic tool that does not address the primary life-threatening problem of malignant hypertension causing encephalopathy. The initial stabilization of the neurological emergency takes precedence [1].

- Option 3 (Start an IV line and prepare for antihypertensive medication administration): This is a critical action, but it is not the highest priority before the neurological assessment is complete. The choice of antihypertensive agent and the target blood pressure reduction are directly informed by the neurological exam. For instance, the management strategy for an acute ischemic stroke differs from that of an intracerebral hemorrhage or PRES. Starting an IV is a preparatory step, but the assessment must come first to ensure the subsequent therapy is safe and appropriate [1].

Pathophysiological Integration

The patient’s blood pressure of 230/125 mmHg has overwhelmed the brain’s autoregulatory capacity, leading to breakthrough vasodilation, endothelial dysfunction, and the vasogenic edema characteristic of PRES. This explains the severe headache, blurred vision, and confusion. The concurrent chest pain suggests increased myocardial oxygen demand and potential left ventricular strain from the extreme afterload. The nurse’s immediate priority is to quantify the neurological insult through a focused assessment, as the findings will dictate the entire treatment trajectory. Timely and effective blood pressure management in such neurologic emergencies requires this precise, assessment-driven approach to balance rapid intervention with patient safety [1].References (research sources)

- [1]Blood Pressure Management in Neurologic Emergencies.Research articleWagstaff H, Ledyard HK. (2026) · DOI: 10.1016/j.emc.2025.08.008

## 임상 시나리오

Hypertensive Emergency with Neurological SignsPrioritizing Assessment Before Intervention
In a patient with a BP of 230/125 mmHg and confusion, the highest priority nursing action is a focused neurological assessment to establish a baseline and detect signs of increased intracranial pressure.

Rapidly lowering blood pressure before this assessment can reduce cerebral perfusion pressure, potentially causing an ischemic stroke or worsening cerebral edema. Titrate antihypertensives to reduce mean arterial pressure by no more than 25% within the first hour.

Clinical AlertDo not administer vasodilators like nitroglycerin as a first-line intervention for a hypertensive emergency with neurological symptoms. The priority is to assess first to avoid precipitating cerebral hypoperfusion.

## 핵심 개념

- **Hypertensive Encephalopathy** — A syndrome of altered mental status, headache, and visual disturbances due to severely elevated blood pressure causing cerebral edema.
- **Hypertensive Emergency** — A severe blood pressure elevation (typically >180/120 mmHg) with evidence of acute end-organ damage, such as to the brain, heart, or kidneys.
- **Increased Intracranial Pressure (ICP)** — A rise in pressure inside the skull that can compromise brain perfusion and function, often presenting with altered consciousness and visual changes.
- **Nursing Priority Setting** — The process of determining the order of nursing actions based on a hierarchy of needs, often starting with airway, breathing, circulation, and neurological status.

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