# Situation: The public health nurse of a Rural Health Unit (RHU) runs a tobacco and alcohol program for tricycle drivers and factory workers in the municipality. At a workplace screening, a 48-year-old tricycle driver who smokes has blood pressure readings of 186/112 mmHg and 184/114 mmHg, taken 5 minutes apart after rest with a correct-size cuff. He has no headache, chest pain, vision change, weakness, confusion, or shortness of breath. A doctor is on duty at the RHU until late afternoon. What should the nurse do?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=627114  
> language: ko  
> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: The public health nurse of a Rural Health Unit (RHU) runs a tobacco and alcohol program for tricycle drivers and factory workers in the municipality.

At a workplace screening, a 48-year-old tricycle driver who smokes has blood pressure readings of 186/112 mmHg and 184/114 mmHg, taken 5 minutes apart after rest with a correct-size cuff. He has no headache, chest pain, vision change, weakness, confusion, or shortness of breath. A doctor is on duty at the RHU until late afternoon. What should the nurse do?

## 보기

1. Estimate his total cardiovascular risk and set follow-up by level
2. Counsel on salt and smoking and recheck in 1 month
3. Refer him to the physician for same-day evaluation **✔ 정답**
4. Call for emergency transport to a hospital right now

**정답: 3**

## 해설

Systolic pressure above 180 mmHg without signs of acute target-organ damage is severe hypertension, not a hypertensive emergency. At this level the nurse does not wait for a total-risk estimate or a routine recheck; she refers him to the physician the same day for confirmation and treatment. Emergency transport is for severe readings with target-organ signs such as chest pain, neurologic deficit, vision change, or breathlessness, which he does not have.

## 심화 해설

A blood pressure of 186/112 mmHg and 184/114 mmHg confirmed on repeat measurement after rest meets the threshold for severe asymptomatic hypertension. The key clinical distinction here is between a markedly elevated reading that requires prompt medical evaluation and a true hypertensive emergency, which demands immediate transport.

In this scenario, the driver has no headache, chest pain, visual disturbance, focal weakness, confusion, or dyspnea. These are the sentinel symptoms of acute target-organ damage affecting the brain, heart, retina, or kidneys. Their absence means the elevated pressure is not causing ongoing end-organ injury at this moment. A systolic pressure above 180 mmHg without target-organ symptoms is classified as severe hypertension, not a hypertensive emergency. The appropriate response is same-day referral to the physician who is available at the RHU, not emergency transport.

Watch out! The distinction between severe asymptomatic hypertension and hypertensive emergency is based on the presence or absence of acute target-organ damage, not solely on the blood pressure number. A patient with 186/112 mmHg and no symptoms is managed differently from one with 170/100 mmHg and acute pulmonary edema or encephalopathy.

The rationale for same-day physician referral rather than a routine one-month recheck relates to the natural history of uncontrolled severe hypertension. While this patient is not in immediate danger, sustained pressures at this level substantially increase the risk of stroke, myocardial infarction, and renal injury over days to weeks. Delaying evaluation by a month would leave a modifiable high-risk window open. At this blood pressure level, the nurse does not wait for a total cardiovascular risk estimate or a routine recheck; physician confirmation and treatment initiation should occur the same day.

The distinction between emergency transport and same-day referral also reflects the different care pathways. Emergency transport is indicated when severe readings are accompanied by signs such as chest pain, neurologic deficit, vision change, or breathlessness. This patient has none of those findings, so calling for emergency transport would over-triage and divert resources from true emergencies. Conversely, simply counseling on salt and smoking and rechecking in one month would under-triage a finding that warrants prompt medical attention.

From a primary care and health systems perspective, the setting matters. A Rural Health Unit with a physician on duty until late afternoon is equipped to evaluate, confirm, and initiate or adjust antihypertensive therapy. In limited-resource settings, hypertension control is often poor because of gaps in follow-up and health system capacity. Same-day referral within the existing facility is a feasible, high-yield action that does not require transfer to a distant hospital. The nurse’s role is to recognize the severity, facilitate timely physician evaluation, and ensure the patient understands the urgency of not deferring care.

The table below summarizes the triage logic for markedly elevated blood pressure readings in the absence of acute symptoms.

| Clinical situation | Blood pressure pattern | Key features | Nursing action |
| --- | --- | --- | --- |
| Severe asymptomatic hypertension | Systolic above 180 mmHg or diastolic above 110–120 mmHg | No headache, chest pain, neurologic deficit, vision change, dyspnea, or confusion | Same-day referral to physician for confirmation and treatment; no emergency transport |
| Hypertensive emergency | Severe elevation with acute target-organ damage | Chest pain, focal weakness, altered mental status, visual disturbance, pulmonary edema, acute kidney injury | Immediate emergency transport and close monitoring |
| Elevated or stage 1 hypertension | Lower than 180/110 mmHg without symptoms | No acute target-organ signs | Lifestyle counseling, risk estimation, scheduled follow-up |

Key point! The nurse’s decision hinges on target-organ assessment, not on the absolute blood pressure value alone. A thorough symptom review for neurologic, cardiac, retinal, and renal involvement is the critical step that separates same-day referral from emergency transport.

The blood pressure was measured with a correct-size cuff after rest, and readings were taken 5 minutes apart. This confirms the elevation is not a measurement artifact or a transient stress response. Repeated severe readings in a primary care setting should trigger prompt physician evaluation rather than watchful waiting. In this case, the physician is physically present at the RHU until late afternoon, making same-day referral both appropriate and logistically straightforward.

## 임상 시나리오

Severe Asymptomatic Hypertension TriageDistinguishing urgent referral from emergency transport
A systolic BP above 180 mmHg without acute target-organ symptoms is classified as severe asymptomatic hypertension, not a hypertensive emergency. The nurse should arrange same-day physician referral for confirmation and treatment initiation.

Assess for sentinel symptoms of acute target-organ damage: headache, chest pain, vision change, focal weakness, confusion, or dyspnea. Their absence guides the decision away from emergency transport.

CautionEmergency transport is indicated only when severe readings coexist with target-organ signs such as neurologic deficit, chest pain, or breathlessness. Do not use the BP number alone to trigger emergency activation.

## 핵심 개념

- **severe asymptomatic hypertension** — Systolic blood pressure >180 mmHg without signs of acute target-organ damage; requires prompt medical evaluation but not emergency transport.
- **hypertensive emergency** — Severely elevated blood pressure with acute target-organ damage (brain, heart, retina, kidney); requires immediate treatment and transport.
- **target-organ damage** — Acute injury to organs such as brain (confusion, weakness), heart (chest pain), or lungs (dyspnea) caused by severely elevated blood pressure.
- **same-day referral** — Prompt referral to a physician within the same day for evaluation and treatment initiation, appropriate for severe asymptomatic hypertension.

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