# 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?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=540328  
> language: ko  
> subject: Adult Health

## 문제

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?

## 보기

1. Administer sublingual nitroglycerin immediately to rapidly reduce blood pressure
2. Place the patient in Trendelenburg position to improve cerebral perfusion
3. Initiate continuous cardiac monitoring and prepare for controlled blood pressure reduction **✔ 정답**
4. Give a bolus of normal saline to improve perfusion before antihypertensive therapy

**정답: 3**

## 해설

In hypertensive crisis with neurological symptoms, priority is continuous cardiac monitoring and controlled BP reduction to prevent organ damage while avoiding precipitous drops. Other options are incorrect as they may cause harm or delay essential care.

## 심화 해설

Understanding the Clinical Scenario

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].

Priority Action: Controlled Blood Pressure Reduction

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].

Why Other Options Are Incorrect or Harmful

- **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.

References (research sources)

- [1]Determinants of hypertensive crisis among hypertensive patients at adult emergency departments of public hospitals in eastern Ethiopia, 2023: A case-control study.Research articleWondimneh F, Getachew M, Teshager T, Legesse H, Alemu A, Ketema I, Tesfaye D, Mossie Y, Muluberhan N, Meseret F. (2025) · DOI: 10.1371/journal.pone.0326055

## 임상 시나리오

Hypertensive Emergency in CKD: Priority Nursing ActionControlled reduction over rapid normalization
For a dialysis patient presenting with severe hypertension and neurological symptoms, immediately initiate continuous cardiac monitoring and prepare for controlled blood pressure reduction with IV agents like nicardipine.

The target is to lower mean arterial pressure by no more than 25% within the first hour to prevent cerebral hypoperfusion and ischemic stroke.

CautionAvoid rapid-acting vasodilators (e.g., sublingual nitroglycerin) and fluid boluses in this fluid-overloaded state. Do not place the patient in Trendelenburg position as it elevates intracranial pressure.

## 핵심 개념

- **Hypertensive Emergency** — Severe BP elevation (>180/120 mmHg) with acute target-organ damage (e.g., encephalopathy, intracranial hemorrhage, acute heart failure) requiring controlled reduction, not rapid normalization.
- **Controlled Blood Pressure Reduction** — The strategy of lowering mean arterial pressure by no more than 25% within the first hour using titratable IV agents to prevent ischemic events in cerebral, coronary, and renal circulations.
- **Hypertensive Encephalopathy** — A syndrome of severe hypertension accompanied by headache, vomiting, visual disturbances, and altered mental status due to cerebral edema and loss of autoregulation.

## 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 58-year-old patient presents to the emergency department with a blood pressure of 220/12…](https://mymerci.kr/pages/nclex_q.php?qn_id=540326)
- [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 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._