# A nurse is caring for a patient experiencing a hypertensive crisis with a blood pressure of 200/115 mmHg, severe headache, and vomiting. Which nursing action should be the FIRST priority?

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## 문제

A nurse is caring for a patient experiencing a hypertensive crisis with a blood pressure of 200/115 mmHg, severe headache, and vomiting. Which nursing action should be the FIRST priority?

## 보기

1. Administer sublingual nitroglycerin immediately
2. Place the patient in Trendelenburg position
3. Prepare for immediate IV antihypertensive medication administration
4. Assess neurological status **✔ 정답**

**정답: 4**

## 해설

In hypertensive crisis, assessment (especially neurological) is the first priority to detect complications like encephalopathy before intervention. Immediate medication without assessment risks precipitous BP drops and ischemia.

## 심화 해설

Clinical Context & Priority Setting

In a hypertensive crisis, the immediate goal is to differentiate between a hypertensive emergency and hypertensive urgency. The presence of a severe headache and vomiting in a patient with a blood pressure of 200/115 mmHg strongly suggests a hypertensive emergency, indicating acute, ongoing target organ damage, most critically within the central nervous system. The first nursing action must be a focused assessment to confirm the nature and severity of this damage before any intervention is initiated.

Why Not Immediate Medication or Positioning?

Administering an antihypertensive agent, such as preparing for IV medication (Option 3) or giving sublingual nitroglycerin (Option 1), without a prior neurological assessment is dangerous. A rapid, uncontrolled drop in blood pressure can reduce cerebral perfusion pressure, potentially leading to an ischemic stroke. The neurological exam establishes a baseline and helps rule out an acute stroke, which would drastically alter the treatment goals. Similarly, placing the patient in Trendelenburg position (Option 2) is contraindicated as it increases intracranial pressure, worsening the patient's neurological status.

Pathophysiology & Clinical Reasoning

The symptoms of severe headache and vomiting are classic signs of increased intracranial pressure (ICP) and cerebral edema resulting from a sudden, critical elevation in systemic blood pressure that overwhelms cerebral autoregulation. The study by Razzak et al. highlights that acute severe hypertension, defined as a systolic blood pressure of ≥180 mm Hg, is a frequent emergency presentation with significant risks for mortality and hospitalization [1]. The assessment of neurological status directly evaluates the impact of this pressure surge on the brain, the most vulnerable organ in this scenario. This assessment guides all subsequent decisions, including the choice, route, and rate of antihypertensive therapy.References (research sources)

- [1]Assessing the impact of acute severe hypertension in the emergency department: A prospective cohort study in Karachi, Pakistan.Research articleRazzak JA, Ali N, Khan U, Ismail M, Khan BA, Raheem A, Agrawal P, Bhatti J. (2024) · DOI: 10.1371/journal.pgph.0003948

## 임상 시나리오

Hypertensive Crisis: Initial Nursing PriorityAssess Before You Act to Prevent Iatrogenic Stroke
In a patient with 200/115 mmHg BP and neurological symptoms, the first priority is a focused neurological assessment. This differentiates a true hypertensive emergency (target organ damage) from urgency and establishes a baseline.

Symptoms like severe headache and vomiting indicate potential increased intracranial pressure (ICP). Do not place the patient in Trendelenburg position, as this further elevates ICP.

CautionNever administer IV or sublingual antihypertensives before a neurological exam. A rapid, uncontrolled drop in BP can reduce cerebral perfusion pressure (CPP) and cause an ischemic stroke. Treatment goals change if an acute stroke is found.

## 핵심 개념

- **Hypertensive Emergency** — A severe BP elevation (>180/120 mmHg) with evidence of acute target organ damage, such as neurological deficits or papilledema.
- **Cerebral Autoregulation** — The brain's ability to maintain constant blood flow despite changes in systemic blood pressure; it fails during extreme hypertension, leading to edema.
- **Cerebral Perfusion Pressure (CPP)** — The net pressure gradient driving blood flow to the brain, calculated as MAP minus ICP; it must be maintained to prevent ischemia.

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