Malignant hypertension Flashcards
The advanced practice registered nurse (APRN) is performing an initial assessment on a 32-year-old patient who is 22 weeks pregnant. She presents to the emergency department experiencing fatigue, headache, and visual changes. The patient’s neurologic exam is grossly nonfocal despite her reported symptoms. Her blood glucose level is 140. Her vital signs are as follows: T 36.8, BP 165/90, HR 100, RR 20. A urine dipstick reveals proteinuria. Based on this information, which of the following interventions will the APRN recommend?
A. Aggressive reduction in blood pressure
B. Administration of subcutaneous insulin
C. Aggressive fluid resuscitation
D. Normalization of blood pressure over 24–48 hours
Correct Answer: D. Normalization of blood pressure over 24–48 hours
Rationale:
This patient’s presentation is consistent with preeclampsia—hypertension (165/90 mm Hg), proteinuria, and neurological symptoms (headache and visual changes). In preeclampsia, blood pressure should be lowered gradually over 24–48 hours to avoid compromising uteroplacental perfusion. Aggressive blood pressure reduction, insulin, or aggressive fluid resuscitation are not appropriate interventions in this context.
- (Malignant HTN / Will Kill)
In malignant hypertension with encephalopathy, which urgent approach prevents end-organ damage?
A. Delayed blood pressure management
B. Rapid but controlled BP reduction by ~20–25%
C. Aggressive fluid resuscitation
D. Complete sedation only
B. Rapid but controlled BP reduction by ~20–25%
Rationale: Malignant hypertension (hypertensive emergency) with hypertensive encephalopathy requires urgent but controlled blood pressure reduction to prevent end-organ damage (e.g., stroke, retinal hemorrhage, renal failure). The goal is to reduce mean arterial pressure (MAP) by ~20–25% within the first hour to prevent cerebral ischemia or hypoperfusion.
Malignant HTN / Common Finding)
Which fundoscopic feature is commonly observed in malignant hypertension?
A. Clear retinal vessels
B. Papilledema with hemorrhages
C. Cotton-wool spots only in mild HTN
D. Subconjunctival hemorrhage
B. Papilledema with hemorrhages
Rationale:
Malignant hypertension is a hypertensive emergency characterized by severe BP elevation with end-organ damage, including hypertensive retinopathy. The most concerning fundoscopic finding in malignant hypertension is papilledema (optic disc swelling due to increased intracranial pressure) along with retinal hemorrhages, exudates, and cotton-wool spots.
- Malignant hypertension is characterized by:
A. Mildly elevated blood pressure with no end-organ damage
B. Severe hypertension with rapid end-organ damage (e.g., retinal hemorrhages, encephalopathy)
C. Normotension
D. Only systolic hypertension
o
Answer: B
o Rationale: Malignant hypertension involves extremely high blood pressure with signs of acute end-organ damage.
- Which complication “will kill your patient” in malignant hypertension if not urgently managed?
A. Mild headache
B. Hypertensive encephalopathy and intracerebral hemorrhage
C. Minor palpitations
D. Slight leg swelling
o Answer: B
o Rationale: Malignant hypertension can lead to cerebral hemorrhage and encephalopathy, both of which are life-threatening.
- Which of the following is “common” in the initial presentation of malignant hypertension?
A. Gradual weight loss
B. Blurry vision with retinal hemorrhages
C. Chronic cough
D. Occasional dizziness
o Answer: B
o Rationale: Blurry vision and retinal hemorrhages are common findings in malignant hypertension due to acute vascular damage
- What is the immediate management goal in a hypertensive emergency such as malignant hypertension?
A. Slowly lower blood pressure over several days
B. Rapid reduction of blood pressure by 20-25% in the first 1-2 hours
C. Increase salt intake
D. Avoid any pharmacologic therapy
o Answer: B
o Rationale: Rapid yet controlled BP reduction is essential to limit further end-organ damage while avoiding hypoperfusion.
- Which intravenous agent is “common” in the management of malignant hypertension?
A. Oral nifedipine
B. IV nitroprusside
C. High-dose aspirin
D. Subcutaneous heparin
o Answer: B
o Rationale: Nitroprusside is often used for rapid blood pressure control in hypertensive emergencies.
What will kill your patient (ABCs) –
recognizing life‐threatening complications (e.g., end-organ damage, stroke, MI).
What will harm your patient –
avoiding iatrogenic pitfalls or inappropriate management.
What is really common – .
identifying frequent clinical findings and diagnostic nuances
- A hypertensive crisis is defined as blood pressure greater than which of the following thresholds?
A. SBP >140 mm Hg or DBP >90 mm Hg
B. SBP >160 mm Hg or DBP >100 mm Hg
C. SBP >180 mm Hg or DBP >120 mm Hg
D. SBP >200 mm Hg or DBP >130 mm Hg
o Answer: C
o Rationale: A hypertensive crisis is typically defined as a systolic BP above 180 mm Hg or a diastolic BP above 120 mm Hg.
- Which of the following best differentiates hypertensive urgency from hypertensive emergency?
A. The presence or absence of end-organ damage
B. The absolute blood pressure values
C. The age of the patient
D. The speed of blood pressure measurement
o Answer: A
o Rationale: Hypertensive emergency involves end-organ damage, whereas urgency does not.
- What is the one-year mortality rate approximately associated with hypertensive crisis?
A. 2%
B. 5%
C. 9%
D. 15%
o Answer: C
o Rationale: The one-year mortality rate for hypertensive crisis is approximately 9%.
- Which of the following pathophysiologic mechanisms contributes most to end-organ damage in hypertensive emergency?
A. Increased cardiac output
B. Activation of renin-angiotensin and catecholamine systems causing vasoconstriction
C. Decreased vascular permeability
D. Reduced sympathetic tone
o Answer: B
o Rationale: An influx of vasoconstrictors increases systemic vascular resistance, leading to endothelial injury and subsequent end-organ damage.
- Which end-organ is most commonly affected in hypertensive crisis?
A. Liver
B. Brain
C. Pancreas
D. Spleen
o Answer: B
o Rationale: The brain is commonly affected, manifesting as encephalopathy, stroke, or seizure due to cerebral edema and ischemia.
- A patient presents with BP 190/125 mm Hg and a normal neurologic exam. This scenario is most consistent with:
A. Hypertensive emergency
B. Hypertensive urgency
C. Malignant hypertension
D. Preeclampsia.
o Answer: B
o Rationale: Without signs of end-organ damage, the patient has hypertensive urgency
- In hypertensive emergency, what is the recommended initial reduction in blood pressure within the first 1–2 hours?
A. 5% reduction
B. 10% reduction
C. 20–25% reduction
D. 50% reduction
o Answer: C
o Rationale: The goal is to reduce blood pressure by 20–25% within the first 1–2 hours to prevent further end-organ damage.
- Which of the following drugs is considered first-line for hypertensive emergencies in non-pregnant patients?
A. Oral amlodipine
B. Intravenous labetalol
C. Oral lisinopril
D. Sublingual nitroglycerin
o Answer: B
o Rationale: IV labetalol is commonly used because it is rapidly titratable and effective in lowering blood pressure in emergencies.
- What is a potential iatrogenic harm when lowering blood pressure too rapidly in hypertensive emergency?
A. Rebound hypertension
B. End-organ hypoperfusion
C. Excessive sedation
D. Development of tachycardia
o Answer: B
o Rationale: Excessively rapid BP reduction can lead to hypoperfusion of vital organs, risking ischemia.
- Which of the following is the drug of choice for managing hypertensive emergency in pregnancy?
A. Intravenous nitroprusside
B. Oral enalapril
C. Intravenous labetalol
D. Oral hydralazine
o Answer: C
o Rationale: IV labetalol is preferred for hypertensive emergencies in pregnancy due to its safety profile.
- In a hypertensive crisis, which physical exam component is crucial for evaluating end-organ damage?
A. Abdominal exam
B. Neurologic exam
C. Skin exam
D. Musculoskeletal exam
o Answer: B
o Rationale: A neurologic exam helps assess for encephalopathy, stroke, or seizure, common signs of end-organ damage.
- When measuring blood pressure in a suspected hypertensive crisis, which is most important?
A. Using a small cuff
B. Taking the reading in both arms
C. Relying on automated monitors only
D. Measuring in the standing position
o Answer: B
o Rationale: Measuring in both arms can help rule out conditions like aortic dissection and ensures accuracy.
- What is a common finding on fundoscopic exam in hypertensive emergency?
A. Microaneurysms
B. Papilledema
C. Cataracts
D. Retinal detachment
o Answer: B
o Rationale: Papilledema is commonly seen in hypertensive emergency as a sign of increased intracranial pressure and end-organ damage.