CH 36: Hypertensive Crisis Flashcards
A 52-year-old male with a history of uncontrolled hypertension arrives at the emergency department with a BP of 224/136 mm Hg. He reports a severe headache, blurred vision, and confusion. Physical examination reveals papilledema and bilateral lower extremity edema.
Which of the following findings indicate that the patient is experiencing a hypertensive emergency rather than a hypertensive urgency?
A. Systolic BP greater than 180 mm Hg
B. Presence of target organ damage
C. Lack of medication adherence
D. Complaint of headache
B. Presence of target organ damage
Rationale: The key distinction between a hypertensive emergency and hypertensive urgency is target organ damage. This patient exhibits signs of encephalopathy (confusion), retinopathy (papilledema), and possible heart failure (lower extremity edema), confirming hypertensive emergency.
Which of the following complications can result from an untreated hypertensive emergency? (SATA)
A. Stroke
B. Myocardial infarction
C. Chronic stable angina
D. Aortic dissection
E. Nephropathy
A. Stroke
B. Myocardial infarction
D. Aortic dissection
E. Nephropathy
Rationale: Hypertensive emergencies can lead to acute life-threatening complications such as stroke, MI, aortic dissection, and kidney damage. Chronic stable angina (C) is more likely associated with hypertensive urgency, not emergency.
A 65-year-old woman is admitted to the ICU with a BP of 210/130 mm Hg. She is diagnosed with a hypertensive emergency and started on IV nitroprusside.
What is the primary goal of IV antihypertensive therapy in this patient?
A. Lower BP as quickly as possible to prevent further organ damage
B. Reduce BP to normal levels within 30 minutes
C. Maintain BP at 220/140 mm Hg for cerebral perfusion
D. Gradually lower BP by no more than 20-25% in the first hour
D. Gradually lower BP by no more than 20-25% in the first hour
Rationale: Rapidly lowering BP can lead to ischemia of vital organs due to inadequate perfusion. The goal is to reduce BP in a controlled manner, typically by 20-25% in the first hour, then gradually normalize it over the next 24-48 hours.
Which of the following is the preferred route of medication administration for a hypertensive emergency?
A. Intravenous
B. Oral
C. Subcutaneous
D. Transdermal
A. Intravenous
Rationale: IV administration allows for rapid titration and immediate BP control, which is essential in hypertensive emergencies.
A nurse is monitoring a patient receiving IV sodium nitroprusside for hypertensive crisis. Which assessments should the nurse prioritize? (SATA)
A. Continuous BP monitoring
B. Signs of cyanide toxicity
C. Neurologic status
D. Urine output
E. Bowel sounds
A. Continuous BP monitoring
B. Signs of cyanide toxicity
C. Neurologic status
D. Urine output
Rationale: Nitroprusside can cause rapid BP drops (A) and cyanide toxicity (B) with prolonged use. Neurologic changes (C) may indicate worsening encephalopathy or stroke, while urine output (D) reflects renal function and perfusion.
A 30-year-old male is brought to the ED with a BP of 230/142 mm Hg. He has a history of recreational drug use. His pupils are dilated, and he is agitated and tachycardic.
Which drug is most likely responsible for this hypertensive crisis?
A. Heroin
B. Benzodiazepines
C. Cocaine
D. Marijuana
C. Cocaine
Rationale: Cocaine, along with amphetamines and PCP, is a common cause of drug-induced hypertensive crisis. It leads to severe vasoconstriction, which can result in stroke, MI, or encephalopathy.
Which interventions should be included in the care plan for a patient experiencing a hypertensive crisis due to cocaine use? (SATA)
A. Administer benzodiazepines
B. Use beta-blockers as first-line treatment
C. Provide IV antihypertensives such as nicardipine
D. Avoid rapid BP reduction
E. Initiate seizure precautions
A. Administer benzodiazepines
C. Provide IV antihypertensives such as nicardipine
D. Avoid rapid BP reduction
E. Initiate seizure precautions
Rationale: Benzodiazepines (A) help manage agitation and sympathetic overactivity. Nicardipine (C) is preferred over beta-blockers (B) due to concerns about unopposed alpha-stimulation worsening hypertension. Seizure precautions (E) are necessary due to increased risk.
A patient with hypertensive urgency is prescribed oral clonidine. What is the nurse’s priority teaching point?
A. “Take this medication on an empty stomach.”
B. “Do not stop taking this medication suddenly.”
C. “Monitor your pulse for bradycardia.”
D. “Expect a dry cough as a side effect.”
B. “Do not stop taking this medication suddenly.”
Rationale: Clonidine should not be abruptly discontinued as it can lead to rebound hypertension, which may precipitate a hypertensive crisis.
Which patient is at highest risk for developing a hypertensive crisis?
A. A 45-year-old with controlled hypertension taking lisinopril daily
B. A 60-year-old with newly diagnosed hypertension and no medication history
C. A 50-year-old who stopped taking his antihypertensive medication last week
D. A 35-year-old with gestational hypertension at 30 weeks gestation
C. A 50-year-old who stopped taking his antihypertensive medication last week
Rationale: Nonadherence or abrupt discontinuation of antihypertensive medications is a major cause of hypertensive crisis.
A patient in hypertensive crisis develops sudden-onset severe chest pain radiating to the back. What is the nurse’s priority action?
A. Administer IV beta-blockers
B. Perform a 12-lead ECG
C. Obtain a CT scan of the chest
D. Notify the provider immediately
D. Notify the provider immediately
Rationale: Sudden severe chest pain with radiation suggests an aortic dissection, a life-threatening complication requiring immediate intervention.
Which factors increase a patient’s risk for hypertensive crisis? (SATA)
A. Poor medication adherence
B. High sodium diet
C. Chronic alcohol use
D. Hypokalemia
E. History of diabetes
A. Poor medication adherence
B. High sodium diet
C. Chronic alcohol use
E. History of diabetes
Rationale: Medication nonadherence (A), excessive sodium intake (B), chronic alcohol use (C), and diabetes (E) all contribute to poor BP control.
Which symptom in a hypertensive crisis patient suggests impending encephalopathy?
A. Sudden weakness in one limb
B. Severe, persistent headache
C. Nausea and vomiting
D. Altered mental status
D. Altered mental status
Rationale: Encephalopathy manifests as confusion, restlessness, or decreased LOC due to cerebral edema from severe hypertension.
Which symptom in a hypertensive crisis patient suggests impending encephalopathy?
A. Sudden weakness in one limb
B. Severe, persistent headache
C. Nausea and vomiting
D. Altered mental status
D. Altered mental status
Rationale: Encephalopathy manifests as confusion, restlessness, or decreased LOC due to cerebral edema from severe hypertension.
Which lab finding would be most concerning in a patient with hypertensive emergency?
A. Elevated creatinine
B. Hyperkalemia
C. Hyponatremia
D. Increased hemoglobin
A. Elevated creatinine
Rationale: Elevated creatinine indicates renal involvement, a sign of target organ damage in hypertensive emergencies.
A 50-year-old male with a history of untreated hypertension presents with a BP of 240/150 mm Hg. He is experiencing severe headache, nausea, vomiting, and confusion. Which of the following is the most likely cause of his symptoms?
A. Hypertensive encephalopathy
B. Acute myocardial infarction
C. Pulmonary edema
D. Aortic dissection
A. Hypertensive encephalopathy
Rationale: Hypertensive encephalopathy is the most likely cause of these symptoms in the context of severely elevated blood pressure. It is characterized by cerebral edema resulting from increased blood pressure, which disrupts cerebral function and leads to symptoms such as severe headache, nausea, vomiting, and confusion. These manifestations occur due to increased capillary permeability in the brain. The other conditions listed would present with different symptoms, such as chest pain or shortness of breath, not confusion and vomiting.
A patient with hypertensive crisis is admitted to the ICU. The nurse is assessing for complications of hypertensive encephalopathy. Which of the following signs would indicate potential cerebral edema? (SATA)
A. Nausea and vomiting
B. Seizures
C. Papilledema
D. Severe chest pain
E. Decreased level of consciousness
A. Nausea and vomiting
B. Seizures
C. Papilledema
E. Decreased level of consciousness
Rationale: Nausea and vomiting (A), seizures (B), papilledema (C), and decreased level of consciousness (E) are all signs of cerebral edema in hypertensive encephalopathy. Cerebral edema occurs due to increased blood pressure and the resulting disruption of the blood-brain barrier, leading to fluid accumulation in the brain. These signs are direct consequences of this edema and increased intracranial pressure. Severe chest pain (D) is not a typical symptom of cerebral edema but would be more indicative of cardiac involvement such as a myocardial infarction or aortic dissection.
A patient with hypertensive crisis develops sudden chest and back pain, accompanied by a decrease in peripheral pulses. What is the nurse’s most immediate concern?
A. Pulmonary edema
B. Myocardial infarction
C. Aortic dissection
D. Renal failure
C. Aortic dissection
Rationale: Aortic dissection is a life-threatening complication of hypertensive crisis that can cause sudden, severe chest and back pain. It results from a tear in the inner layer of the aorta, which can disrupt blood flow and lead to decreased pulses in the extremities. Prompt diagnosis and intervention are critical to prevent further complications, such as rupture or organ failure. The other options are not as strongly associated with the combination of chest/back pain and absent pulses.
A patient with hypertensive crisis exhibits exudates, hemorrhages, and papilledema on retinal examination. These findings suggest damage to which organ system?
A. Cardiovascular system
B. Renal system
C. Nervous system
D. Ocular system
D. Ocular system
Rationale: Retinal findings such as exudates, hemorrhages, and papilledema indicate damage to the ocular system, specifically the retina, as a result of elevated blood pressure. Hypertensive crisis can cause changes in the retinal vasculature, including these manifestations, due to the increased pressure affecting the blood vessels in the eyes. These findings are not typically seen in the cardiovascular, renal, or nervous systems, even though hypertensive crisis can affect these organ systems.
A 60-year-old female with poorly controlled hypertension presents with elevated BP (220/140 mm Hg) and complaints of fatigue, nausea, and oliguria. The nurse suspects acute kidney injury (AKI) due to hypertensive crisis. Which of the following laboratory findings would confirm the diagnosis of AKI?
A. Decreased creatinine clearance
B. Elevated blood urea nitrogen (BUN) and creatinine
C. Elevated sodium levels
D. Decreased urine osmolality
B. Elevated blood urea nitrogen (BUN) and creatinine
Rationale: Elevated BUN and creatinine are classic signs of acute kidney injury (AKI), confirming that the kidneys are not effectively filtering waste products from the blood. In the case of hypertensive crisis, this could be due to damage to the renal vasculature, leading to reduced kidney function. Decreased creatinine clearance (A) could also be seen with renal impairment, but BUN and creatinine are more directly elevated in AKI. Elevated sodium levels (C) and decreased urine osmolality (D) are not specific indicators of AKI.
A patient with a history of hypertensive crisis is receiving IV antihypertensive medication. The nurse is concerned about the potential for rapid BP reduction. What is the most serious consequence of lowering BP too quickly in a hypertensive crisis?
A. Renal failure
B. Myocardial infarction
C. Stroke
D. Pulmonary edema
C. Stroke
Rationale: Rapid reduction in blood pressure can lead to a decrease in cerebral perfusion, which may precipitate ischemic stroke, especially in patients with pre-existing vascular disease. This is the most serious consequence of lowering BP too quickly in a hypertensive crisis. While renal failure, MI, and pulmonary edema are serious complications, they are more commonly associated with prolonged, uncontrolled hypertension rather than rapid BP reduction.
A 45-year-old male is admitted with hypertensive emergency (BP 230/150 mm Hg). He is experiencing chest pain and shortness of breath. Which of the following interventions should the nurse implement first?
A. Administer IV morphine
B. Initiate IV antihypertensive therapy
C. Administer oxygen via nasal cannula
D. Obtain an ECG
C. Administer oxygen via nasal cannula
Rationale: The first priority is to ensure adequate oxygenation, especially since the patient is experiencing chest pain and shortness of breath. Oxygen via nasal cannula should be administered to prevent hypoxia and reduce the workload on the heart. After ensuring oxygenation, IV antihypertensive therapy (B) can be initiated to control BP. Morphine (A) may be indicated later for pain relief, but oxygenation should always be prioritized. Obtaining an ECG (D) is important, but it can be done after addressing immediate airway and oxygenation needs.
A patient with hypertensive crisis presents with confusion, headache, and blurred vision. What diagnostic test is most appropriate to assess for possible cerebral involvement?
A. MRI of the brain
B. Serum potassium level
C. Chest X-ray
D. Renal ultrasound
A. MRI of the brain
Rationale: MRI of the brain is the most appropriate diagnostic test to assess for cerebral involvement, such as hypertensive encephalopathy or potential stroke, in a patient with symptoms like confusion, headache, and blurred vision. These symptoms suggest increased intracranial pressure or vascular changes in the brain. A chest X-ray (C) and renal ultrasound (D) would be used to assess cardiac and renal function, but they do not provide information on cerebral complications. Serum potassium level (B) is unrelated to cerebral involvement in this case.
A patient with a hypertensive emergency has been admitted to the ICU. Which action should the nurse prioritize in the initial management of this patient?
A. Administering IV antihypertensive agents
B. Lowering blood pressure by 50% immediately
C. Preparing for an immediate surgical intervention
D. Increasing fluid intake to prevent dehydration
A. Administering IV antihypertensive agents
Rationale: Hypertensive emergencies require hospitalization and IV administration of antihypertensive drugs to control the blood pressure rapidly while monitoring for organ damage. Lowering BP too quickly or too much could cause ischemia and endanger the patient’s life. Surgical intervention is not the first priority unless complications such as aortic dissection arise. Fluid intake is not a priority in hypertensive emergencies unless dehydration is also present.
When managing a hypertensive crisis, which factor primarily determines the treatment approach?
A. The patient’s age
B. The level of systolic BP only
C. The presence of new or progressive target organ damage
D. The patient’s blood pressure prior to admission
C. The presence of new or progressive target organ damage
Rationale: The decision to treat a hypertensive crisis is based on the presence of target organ damage, not just the BP level. The BP is a significant factor, but it’s the organ damage (e.g., encephalopathy, MI, renal failure) that dictates the urgency of the situation and the need for immediate intervention.
The nurse is caring for a patient receiving sodium nitroprusside for a hypertensive emergency. What is the most important intervention during the initial administration of this drug?
A. Administering pain medications to the patient
B. Limiting fluid intake to prevent fluid overload
C. Using a noninvasive BP machine every 30 minutes
D. Monitoring the BP and heart rate every 2-3 minutes
D. Monitoring the BP and heart rate every 2-3 minutes
Rationale: Sodium nitroprusside has a rapid onset of action, and BP should be closely monitored every 2 to 3 minutes to assess the patient’s response and adjust the medication accordingly. Monitoring BP continuously ensures that the drug is titrated appropriately and prevents complications such as hypotension or organ perfusion issues.
What is the recommended target decrease in mean arterial pressure (MAP) during the initial management of a hypertensive emergency?
A. 5% to 10%
B. 10% to 15%
C. 20% to 25%
D. 30% to 40%
C. 20% to 25%
Rationale: The initial goal is to decrease MAP by no more than 20% to 25% to avoid causing a rapid drop in cerebral, coronary, or renal perfusion. A decrease in MAP that is too fast can cause ischemic damage to vital organs.
Which of the following IV antihypertensive medications is most effective in treating hypertensive emergencies?
A. Labetalol
B. Esmolol
C. Sodium nitroprusside
D. Clonidine
C. Sodium nitroprusside
Rationale: Sodium nitroprusside is the most effective IV drug for treating hypertensive emergencies due to its rapid onset and potent vasodilatory effect. It can quickly reduce BP and is often the first-line treatment in these situations.
A patient with hypertensive emergency is receiving IV nitroprusside. The nurse notes a sudden change in the patient’s mental status. What is the most appropriate action?
A. Administer an analgesic medication
B. Notify the healthcare provider immediately
C. Increase the IV rate to improve perfusion
D. Reassess the patient’s blood pressure every 5 minutes
B. Notify the healthcare provider immediately
Rationale: A sudden change in mental status, such as confusion or lethargy, may indicate potential complications like cerebral ischemia or toxic effects of nitroprusside (e.g., cyanide toxicity). Immediate communication with the healthcare provider is necessary to evaluate and manage the patient’s condition.
Which of the following conditions requires special consideration when treating hypertensive emergencies?
A. Stable angina
B. Acute ischemic stroke
C. Type 2 diabetes
D. Hyperthyroidism
B. Acute ischemic stroke
Rationale: In the case of acute ischemic stroke, BP is typically not lowered aggressively because elevated BP can be a compensatory response to improve cerebral perfusion to ischemic brain tissue. Rapidly lowering BP in these patients can impair brain blood flow and worsen outcomes.
A patient with hypertensive urgency is prescribed captopril, a commonly used oral agent. What is the disadvantage of oral antihypertensive therapy in managing hypertensive urgency?
A. It works slower than IV agents
B. It is more expensive than IV medications
C. It cannot be titrated moment to moment
D. It causes significant fluid retention
C. It cannot be titrated moment to moment
Rationale: Oral antihypertensive medications like captopril have a slower onset of action compared to IV drugs and cannot be titrated as precisely or quickly. While they can be effective in managing hypertensive urgency, they do not allow for immediate adjustments based on real-time BP monitoring.
The nurse is caring for a patient on IV labetalol for a hypertensive emergency. What is the most important aspect of monitoring during therapy?
A. Oxygen saturation levels
B. Urine output every 30 minutes
C. Electrocardiogram for dysrhythmias
D. The patient’s pain level
C. Electrocardiogram for dysrhythmias
Rationale: Labetalol, like other adrenergic inhibitors, can cause dysrhythmias and should be monitored with an ECG. This allows for early detection of any cardiac complications such as arrhythmias, which may require intervention.
A nurse is caring for a patient receiving treatment for a hypertensive emergency. The patient has developed pulmonary edema. Which of the following is the most appropriate action to address this complication?
A. Continue titrating IV antihypertensive agents
B. Administer a diuretic as prescribed
C. Increase fluid intake to enhance kidney perfusion
D. Decrease the dose of vasodilators
B. Administer a diuretic as prescribed
Rationale: Pulmonary edema, which is characterized by fluid accumulation in the lungs, is a serious complication of hypertensive emergency. Administering a diuretic helps reduce fluid overload and relieves symptoms of pulmonary edema, improving respiratory status.
The nurse is monitoring a patient who is receiving IV antihypertensive therapy. Which of the following should be assessed frequently to evaluate the effectiveness of the treatment?
A. Temperature and weight
B. Cardiac, lung, and renal systems
C. Fasting blood glucose
D. Serum potassium and sodium levels
B. Cardiac, lung, and renal systems
Rationale: Severe hypertension can cause decompensation of the cardiac, lung, and renal systems, which is why these should be monitored frequently to assess the effectiveness of treatment and to detect any deterioration. This includes monitoring for signs of angina, pulmonary edema, and renal failure.
A patient with hypertensive urgency is being treated in the outpatient setting. Which intervention is appropriate for initial BP reduction?
A. Administering IV vasodilators
B. Encouraging rest in a quiet environment
C. Preparing for immediate transfer to the hospital
D. Increasing fluid intake
B. Encouraging rest in a quiet environment
Rationale: Hypertensive urgency, unlike emergencies, does not involve acute organ damage, and BP can often be reduced by allowing the patient to rest in a quiet environment. This helps reduce stress and triggers a gradual decrease in BP without the need for invasive treatments.
Which of the following is the most important factor in deciding whether a patient with hypertensive emergency requires IV antihypertensive therapy?
A. The patient’s age
B. The duration of hypertension
C. The presence of target organ damage
D. The patient’s weight
C. The presence of target organ damage
Rationale: The presence of target organ damage, such as encephalopathy, MI, or renal failure, is the primary determinant in deciding the need for IV antihypertensive therapy in a hypertensive emergency. BP alone does not dictate treatment; the potential for organ damage does.
A patient with a hypertensive emergency has been stabilized. What is the next step in managing the patient?
A. Transitioning to oral antihypertensive therapy
B. Preparing for discharge immediately
C. Transferring to a general medical floor
D. Monitoring the patient for several more hours
A. Transitioning to oral antihypertensive therapy
Rationale: Once the hypertensive emergency has been stabilized, the next step is transitioning the patient to oral antihypertensive therapy. This allows for long-term management of the patient’s blood pressure, with continued monitoring for any further complications.
The nurse is caring for a patient who is receiving an IV vasodilator for hypertensive emergency. Which of the following should the nurse assess frequently during the initial administration of the medication?
A. Serum electrolyte levels
B. The patient’s level of consciousness
C. Pain intensity
D. Respiratory rate
B. The patient’s level of consciousness
Rationale: Rapid reduction in blood pressure can affect cerebral perfusion, leading to changes in mental status. Frequent assessment of the patient’s level of consciousness helps detect any signs of ischemia or complications related to BP management.
Which medication is commonly used to treat hypertensive urgency in an outpatient setting?
A. Sodium nitroprusside
B. Clonidine
C. Esmolol
D. Fenoldopam
B. Clonidine
Rationale: Clonidine is a common oral antihypertensive used for hypertensive urgency. It is a centrally acting alpha-2 adrenergic agonist that helps lower blood pressure gradually. IV medications like sodium nitroprusside are used for hypertensive emergencies, not urgencies.
A patient with hypertensive emergency is receiving IV labetalol. Which of the following should the nurse do to prevent complications associated with this medication?
A. Administer oxygen via nasal cannula
B. Monitor for dysrhythmias using an ECG
C. Encourage the patient to increase fluid intake
D. Reduce the dosage if the patient complains of dizziness
B. Monitor for dysrhythmias using an ECG
Rationale: Labetalol can cause changes in heart rate and rhythm, making it essential to monitor the patient for dysrhythmias using an ECG. Early detection of any arrhythmias allows for prompt intervention to prevent complications.
What is the primary goal when managing a patient with hypertensive crisis using IV medications?
A. Rapid reduction of BP
B. Preventing all target organ damage
C. Decreasing MAP by no more than 20% to 25%
D. Normalizing BP immediately
C. Decreasing MAP by no more than 20% to 25%
Rationale: The goal in hypertensive crisis is to gradually reduce the MAP by 20% to 25%. A too-rapid reduction can impair organ perfusion and cause ischemic damage. Gradual reduction ensures adequate organ perfusion while lowering BP to safe levels.
The nurse is caring for a patient with hypertensive emergency. Which of the following is a priority action when administering IV antihypertensive drugs?
A. Using a noninvasive BP monitor every 5 minutes
B. Titrating the drug according to MAP or SBP
C. Encouraging the patient to change positions frequently
D. Reducing the IV infusion rate gradually
B. Titrating the drug according to MAP or SBP
Rationale: IV antihypertensive drugs should be titrated based on MAP or SBP to maintain controlled blood pressure and prevent complications. Frequent monitoring of BP is essential to ensure the correct dosage is administered.
A 62-yr-old patient who has no history of hypertension has a blood pressure (BP) of 198/110 mm Hg during a routine wellness check. After reconfirming the BP, which information would the nurse provide to the patient?
a. A BP recheck should be scheduled in a few weeks.
b. Dietary sodium and fat content should be decreased.
c. Diagnosis, treatment, and monitoring will be needed.
d. There is danger of a stroke, requiring hospitalization.
c. Diagnosis, treatment, and monitoring will be needed.
Rationale: A sudden increase in BP in a patient older than age 50 years with no hypertension history or risk factors indicates that the hypertension may be secondary to some other problem. The BP will need treatment and ongoing monitoring. If the patient has no other risk factors, a stroke in the immediate future is unlikely and the BP may be managed as an outpatient. There is no indication that dietary salt or fat intake have contributed to this sudden increase in BP. Reducing intake of salt and fat alone will not be adequate to reduce this BP to an acceptable level.
The registered nurse (RN) is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside. Which nursing action can the nurse delegate to an experienced licensed practical/vocational nurse (LPN/VN)?
a. Evaluate effectiveness of nitroprusside therapy on blood pressure (BP).
b. Assess the patient‘s environment for adverse stimuli that might increase BP.
c. Titrate nitroprusside to decrease mean arterial pressure (MAP) to 115 mm Hg.
d. Set up the automatic noninvasive BP machine to take readings every 15 minutes.
d. Set up the automatic noninvasive BP machine to take readings every 15 minutes.
Rationale: LPN/VN education and scope of practice include the correct use of common equipment such as automatic noninvasive blood pressure machines. Assessment, evaluation, and medication titration require advanced nursing judgment and education, and would be done by RNs.
