# A 58-year-old patient presents to the emergency department with a blood pressure of 220/120 mmHg and severe headache. The patient reports chest pain and shortness of breath. Which nursing action should be the highest priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540326 > language: ko > subject: Adult Health ## 문제 A 58-year-old patient presents to the emergency department with a blood pressure of 220/120 mmHg and severe headache. The patient reports chest pain and shortness of breath. Which nursing action should be the highest priority? ## 보기 1. Administer prescribed antihypertensive medication immediately **✔ 정답** 2. Place the patient in Trendelenburg position to improve cerebral perfusion 3. Encourage the patient to take deep breaths and perform relaxation techniques 4. Obtain a complete medication history before implementing any interventions **정답: 1** ## 해설 In hypertensive crisis with target organ damage, immediate but controlled blood pressure reduction is the priority to prevent complications. Other options are less urgent or potentially harmful in this acute setting. ## 심화 해설 Clinical Reasoning and Priority Setting The patient presents with a blood pressure of 220/120 mmHg, severe headache, chest pain, and shortness of breath. This clinical picture is consistent with a hypertensive emergency, defined as a severe, acute elevation in blood pressure accompanied by evidence of acute hypertension-mediated organ damage [1]. The presence of chest pain and shortness of breath strongly suggests acute myocardial injury or pulmonary edema, while the severe headache raises concern for hypertensive encephalopathy or intracranial hemorrhage. In a hypertensive emergency, the immediate goal is not to normalize blood pressure but to achieve a prompt, controlled reduction to prevent irreversible organ damage. The highest priority nursing action is to administer the prescribed antihypertensive medication without delay. Evidence confirms that hypertensive emergency is potentially life-threatening and requires immediate intervention, as in-hospital mortality rates approach 10% [1]. Delaying treatment to obtain a complete history or attempting non-pharmacological measures first can lead to worsening target organ damage. Regarding the incorrect options: - Placing the patient in a Trendelenburg position is contraindicated. This position increases venous return and intracranial pressure, which can exacerbate cerebral edema and cardiac workload in a patient already experiencing a supply-demand mismatch in the myocardium [4]. - Encouraging deep breaths and relaxation techniques may be appropriate for managing anxiety in stable patients, but these measures are insufficient and inappropriate as a first-line intervention for a hypertensive emergency with ongoing organ injury . - While a complete medication history is important for identifying causes such as nonadherence, obtaining it before implementing interventions delays critical, time-sensitive treatment. In the setting of acute organ damage, pharmacological management takes precedence . The underlying pathophysiology of the chest pain in this context is likely a type 2 myocardial infarction, driven by a severe mismatch between myocardial oxygen supply and demand due to extreme afterload, rather than an acute coronary plaque rupture [4]. Prompt but controlled blood pressure reduction directly addresses this mechanism by decreasing afterload and myocardial oxygen consumption, making it the cornerstone of treatment and the nurse's top priority [4].References (research sources) - [1]Hypertensive CrisisResearch articleAhmed I, Alley WD, Chauhan S, Afzal M. (2026) - [4]Acute Myocardial Injury in the Setting of Hypertensive Emergency: A Case Report.Case reportSaidi S, Moujahid M, Mehssani Z, Nadhil Z, Fellat N. (2026) · DOI: 10.7759/cureus.108957 ## 임상 시나리오 Hypertensive Emergency: Immediate Nursing PriorityRapid Intervention to Prevent Irreversible Organ Damage A blood pressure of 220/120 mmHg with chest pain and severe headache indicates a hypertensive emergency with acute target organ damage. The immediate priority is administering prescribed IV antihypertensives to achieve a controlled BP reduction, not normalization. Avoid placing the patient in Trendelenburg position, as it elevates intracranial pressure and cardiac workload, worsening cerebral edema and myocardial stress. CautionDo not delay treatment for a complete history or non-pharmacological interventions. In-hospital mortality for hypertensive emergency approaches 10%, making rapid pharmacological intervention critical to prevent irreversible damage like stroke or myocardial infarction. ## 핵심 개념 - **Hypertensive Emergency** — Severe BP elevation (>180/120 mmHg) with acute target organ damage (e.g., encephalopathy, MI, pulmonary edema), requiring immediate BP reduction. - **Target Organ Damage** — Acute injury to organs like the heart, brain, or kidneys caused by severely elevated blood pressure. - **Trendelenburg Position** — Supine position with the head lower than the feet; contraindicated in hypertensive crisis due to increased intracranial and cardiac workload. ## 같은 주제 문제 - [A 65-year-old patient presents to the emergency department with severe headache, blurred v…](https://mymerci.kr/pages/nclex_q.php?qn_id=540325) - [A 48-year-old patient presents to the emergency department with a blood pressure of 230/12…](https://mymerci.kr/pages/nclex_q.php?qn_id=540327) - [A 55-year-old patient with a history of chronic kidney disease presents to the emergency d…](https://mymerci.kr/pages/nclex_q.php?qn_id=540328) - [A nurse is caring for a patient experiencing a hypertensive crisis with a blood pressure o…](https://mymerci.kr/pages/nclex_q.php?qn_id=540329) - [A 62-year-old patient presents to the emergency department with a blood pressure of 180/11…](https://mymerci.kr/pages/nclex_q.php?qn_id=540330) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._