# A 63-year-old arrives with repeated BP readings near 226/132 mm Hg, new disorientation, and declining urine output. Creatinine is 2.3 mg/dL, compared with 0.8 mg/dL last month (reference 0.6-1.2). Glucose is normal; urgent evaluation finds no intracranial hemorrhage or aortic dissection. A monitored bed is available and the clinician orders a titratable IV antihypertensive with an individualized reduction target. Select the condition requiring this plan, TWO nursing actions during initial treatment, and TWO physiologic trends that directly evaluate pressure control and kidney perfusion.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=569389&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A 63-year-old arrives with repeated BP readings near 226/132 mm Hg, new disorientation, and declining urine output. Creatinine is 2.3 mg/dL, compared with 0.8 mg/dL last month (reference 0.6-1.2). Glucose is normal; urgent evaluation finds no intracranial hemorrhage or aortic dissection. A monitored bed is available and the clinician orders a titratable IV antihypertensive with an individualized reduction target. Select the condition requiring this plan, TWO nursing actions during initial treatment, and TWO physiologic trends that directly evaluate pressure control and kidney perfusion.

Condition

Select 1
Severe chronic hypertension without acute injury
Transient pain-related elevation with intact organs
White-coat elevation requiring outpatient confirmation
Hypertensive emergency with acute organ dysfunction

Actions to take

Select 2
Use the oral maintenance dose as the sole initial treatment
Titrate the prescribed IV agent to the ordered target
Lower mean arterial pressure by half within the first hour
Perform frequent focused neurologic reassessments
Delay IV titration until the next creatinine result returns

Parameters to monitor

Select 2
Capillary glucose trend during initial treatment
Serial blood pressure during medication titration
Oxygen saturation during the monitored observation
Serial body temperature during the observation period
Hourly urine output during initial treatment

## Explanation

Choose hypertensive emergency; titrate the prescribed IV medication and perform frequent neurologic reassessment. Track serial BP and hourly urine output. The acute mental-status change and creatinine rise demonstrate new organ dysfunction accompanying severe hypertension. Treatment requires monitored, controlled pressure reduction, not merely a response to an isolated high reading. Urine output provides a timely bedside indicator alongside laboratory follow-up.

## In-depth explanation

Correct answer
Choose hypertensive emergency; titrate the prescribed IV medication and perform frequent neurologic reassessment. Track serial BP and hourly urine output.

Why this is correct
The acute mental-status change and creatinine rise demonstrate new organ dysfunction accompanying severe hypertension. Treatment requires monitored, controlled pressure reduction, not merely a response to an isolated high reading. Urine output provides a timely bedside indicator alongside laboratory follow-up.

Clinical picture
Chronic hypertension can shift autoregulation. An abrupt excessive fall can compromise brain or kidney perfusion even when the resulting number looks normal. Follow the individualized prescription and report neurologic or perfusion deterioration.

Memory hook
The emergency is pressure plus acute injury. The treatment goal is controlled improvement, not the fastest possible normal number.

NCLEX decision rule
Use new organ dysfunction to distinguish emergency from severe elevation without acute injury. Do not use absence of one eye or neurologic sign to rule out organ injury elsewhere.

Why the alternatives are wrong
The three alternative conditions presume intact organs or an explanation not supported by the acute changes. An oral-only maintenance plan is unsuitable for the described monitored IV-treatment situation. Halving mean arterial pressure in the first hour risks excessive reduction and hypoperfusion. The existing organ-injury findings justify treatment without waiting for another creatinine result. Glucose, oxygen saturation and temperature can identify other causes of deterioration but do not directly measure pressure control or kidney perfusion. Serial creatinine remains relevant alongside the requested bedside urine-output trend.

Sources
AHA elevated blood pressure in acute care

## Clinical scenario

Practice transfer: Chronic hypertension can shift autoregulation. An abrupt excessive fall can compromise brain or kidney perfusion even when the resulting number looks normal. Follow the individualized prescription and report neurologic or perfusion deterioration.

## Key concepts

- **Target-organ injury** — New damage or dysfunction in organs affected by severe hypertension.
- **Autoregulation** — Adjustment of local vascular resistance to preserve tissue blood flow.
- **Titration** — Stepwise adjustment of a medication to a specified clinical target.

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