NCLEX-RNPhysiological AdaptationMedium
A client with a history of untreated hypertension arrives in the emergency department with a blood pressure of 232/138 mm Hg, severe headache, blurred vision, and confusion. Which action should the nurse take first?
- AAdminister an oral antihypertensive and recheck blood pressure in 1 hour
- BLower the blood pressure to 120/80 mm Hg within the first hour
- CInitiate an IV antihypertensive infusion with continuous blood pressure monitoring
- DPlace the client supine and encourage slow, deep breathing
Show answer & explanationAnswer & explanation
Correct answer: C. Initiate an IV antihypertensive infusion with continuous blood pressure monitoring
This is a hypertensive emergency with evidence of end-organ damage (encephalopathy). Treatment requires a titratable IV antihypertensive (e.g., nicardipine, labetalol) with continuous monitoring, reducing MAP by no more than 25% in the first hour to avoid cerebral hypoperfusion.
Why the other options are wrong
- A. Oral agents act too slowly and lack titratability for a hypertensive emergency.
- B. Rapid normalization can cause cerebral ischemia due to shifted autoregulation.
- D. Positioning and breathing exercises do not address the emergency need for pharmacologic control.
Hypertensive Emergency
Severe blood pressure elevation (>180/120 mm Hg) with evidence of acute end-organ damage, requiring immediate but controlled reduction with IV antihypertensives.
- Reduce MAP by no more than 25% in the first hour to prevent ischemia
- Use titratable IV agents such as nicardipine or labetalol
- Distinguished from hypertensive urgency, which has no organ damage and can be treated orally
Memory trick: Go slow, don't blow the brain—25% max in the first hour