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.
- Which diagnostic evaluation is essential in a patient with hypertensive crisis and neurologic symptoms?
A. Abdominal ultrasound
B. Brain CT scan
C. Echocardiography
D. Chest X-ray
o Answer: B
o Rationale: A CT scan of the brain is indicated to assess for stroke or cerebral edema.
- Which laboratory evaluation might help assess end-organ damage in hypertensive crisis?
A. Serum amylase
B. Renal function tests
C. Serum calcium
D. Coagulation profile
o Answer: B
o Rationale: Renal function tests (BUN, creatinine) help assess for acute kidney injury, a common complication.
- A hypertensive crisis patient with chest pain and ECG changes concerning for ischemia should be managed as a hypertensive emergency. What additional therapy might be indicated?
A. Oral beta-blockers
B. Immediate thrombolytics
C. Supplemental oxygen and nitrates
D. High-dose diuretics
o Answer: C
o Rationale: Chest pain with ischemic changes warrants supportive care including oxygen and nitrates alongside blood pressure management.
- Which of the following is a nonpharmacologic measure in managing hypertensive crisis?
A. Administering IV medications
B. Elevating the head of the bed
C. Immediate surgical intervention
D. Intravenous sedation.
o Answer: B
o Rationale: Nonpharmacologic measures like positioning (head elevation) can help reduce intracranial pressure and promote comfort
- A patient presents with BP 200/130 mm Hg and signs of pulmonary edema. This is most consistent with:
A. Hypertensive urgency
B. Hypertensive emergency
C. Chronic hypertension
D. Pseudohypertension
o Answer: B
o Rationale: Pulmonary edema indicates acute end-organ damage, consistent with hypertensive emergency.
- In the setting of hypertensive crisis due to nonadherence, what is a key management consideration?
A. Ignore medication history
B. Investigate and address the reasons for nonadherence
C. Immediately add multiple new medications
D. Discharge the patient with no changes
o Answer: B
o Rationale: Understanding and addressing nonadherence can help prevent future crises.
- Which endocrine disorder is a potential secondary cause of hypertensive crisis?
A. Hypothyroidism
B. Pheochromocytoma
C. Addison’s disease
D. Type 1 diabetes mellitus.
o Answer: B
o Rationale: Pheochromocytoma can cause episodic surges in blood pressure leading to hypertensive crises
- Which illicit drug is most commonly associated with hypertensive crisis?
A. Marijuana
B. Cocaine
C. Heroin
D. LSD
Answer: B
o Rationale: Cocaine use can cause severe vasoconstriction and is a well-known precipitant of hypertensive crisis.
- What renovascular condition can precipitate a hypertensive crisis?
A. Renal artery stenosis
B. Polycystic kidney disease
C. Urinary tract infection
D. Nephrolithiasis
o Answer: A
o Rationale: Renal artery stenosis can lead to activation of the renin-angiotensin system, triggering a hypertensive crisis.
- What is the primary concern in a hypertensive emergency that “will kill your patient”?
A. Inadequate pain control
B. Progressive end-organ damage leading to cardiac, neurologic, or renal failure
C. Mild headache
D. Transient palpitations
Answer: B
o Rationale: End-organ damage from uncontrolled blood pressure can lead to fatal complications such as stroke, MI, or renal failure.
- A patient with hypertensive crisis is found to have severe headache, nausea, and visual disturbances. Which end-organ is likely involved?
A. Kidney
B. Brain
C. Liver
D. Spleen
o Answer: B
o Rationale: These symptoms suggest neurologic involvement, potentially indicating hypertensive encephalopathy.
- In hypertensive crisis, why is it important to recheck the blood pressure after 5 minutes of the initial reading?
A. To confirm if the patient is experiencing anxiety-induced elevation
B. To measure heart rate accurately
C. To check for orthostatic hypotension
D. To assess respiratory rate
o Answer: A
o Rationale: Repeating the measurement after rest ensures the reading is not falsely elevated due to anxiety or improper technique.
- Which drug is contraindicated in hypertensive emergencies with aortic dissection?
A. Beta-blockers
B. Nitroprusside alone
C. Labetalol
D. Esmolol
o Answer: B
o Rationale: Nitroprusside should not be used alone in aortic dissection because it can increase shear stress; beta-blockade is essential first.
- For a patient with hypertensive emergency complicated by acute kidney injury, which of the following is most critical?
A. Aggressive diuresis
B. Slow and controlled blood pressure reduction
C. Immediate initiation of hemodialysis
D. Rapid fluid restriction
o Answer: B
o Rationale: A controlled BP reduction helps prevent further renal hypoperfusion while avoiding sudden drops that worsen injury.
- In hypertensive crisis, what common laboratory abnormality may indicate ongoing end-organ damage?
A. Elevated serum potassium
B. Elevated serum creatinine
C. Low hemoglobin
D. Elevated bilirubin
o Answer: B
o Rationale: An elevated creatinine level suggests renal injury, a common end-organ effect of hypertensive emergency.
- Which imaging study is most appropriate for evaluating potential cardiac end-organ damage in hypertensive crisis?
A. Abdominal CT
B. Echocardiography
C. Leg Doppler ultrasound
D. Bone scan
o Answer: B
o Rationale: Echocardiography can evaluate left ventricular function, wall motion abnormalities, and signs of ischemia.
- What role does the renin-angiotensin-aldosterone system (RAAS) play in hypertensive crisis?
A. It reduces systemic vascular resistance
B. It increases vasoconstriction and contributes to endothelial injury
C. It solely regulates electrolyte balance
D. It has no role in hypertensive crises
o Answer: B
o Rationale: RAAS activation increases vasoconstriction, contributing to elevated blood pressure and potential endothelial damage.
- Which of the following is a common trigger for hypertensive crisis in hospitalized patients?
A. Medication nonadherence
B. Overuse of salt substitutes
C. Use of sympathomimetic drugs
D. Physical inactivity
o Answer: C
o Rationale: Both illicit and prescribed sympathomimetics (e.g., cocaine, amphetamines) are common precipitants of hypertensive crises.
- What is the significance of end-organ evaluation in a hypertensive crisis?
A. It determines the patient’s cholesterol level
B. It guides the urgency and type of blood pressure management
C. It establishes the need for anticoagulation
D. It identifies possible genetic predispositions
o Answer: B
o Rationale: Evaluating for end-organ damage distinguishes hypertensive urgency from emergency and guides treatment intensity.
- Why is accurate medication reconciliation important in hypertensive crisis evaluation?
A. To determine baseline renal function
B. To identify discontinuations or interactions that may have precipitated the crisis
C. To assess dietary sodium intake
D. To predict future weight loss
o Answer: B
o Rationale: Reviewing medications helps determine if nonadherence or drug interactions contributed to the hypertensive crisis.
- A patient with hypertensive crisis and signs of pulmonary edema should be managed with which approach first?
A. Oral antihypertensives
B. Rapid titration of IV antihypertensive agents with supportive oxygen therapy
C. Immediate coronary angiography
D. Observation only.
o Answer: B
o Rationale: IV agents allow rapid titration to reduce blood pressure safely, while oxygen and supportive care manage pulmonary edema
- Which complication “will harm your patient” if hypertensive emergency is left untreated?
A. Mild headache
B. End-stage renal failure
C. Temporary dizziness
D. Occasional palpitations
o Answer: B
o Rationale: Untreated hypertensive emergency can lead to progressive end-organ damage such as irreversible kidney injury
- What is the role of magnesium sulfate in pregnancy-related hypertensive emergencies?
A. To increase blood pressure
B. To prevent seizures and provide vasodilation
C. To reduce blood glucose
D. To act as a diuretic
o Answer: B
o Rationale: Magnesium sulfate is used to prevent eclamptic seizures and help lower blood pressure in preeclampsia/eclampsia.
- Which of the following is a common clinical feature (“what is really common”) in hypertensive crisis?
A. Persistent cough
B. Severe chest pain
C. Elevated blood pressure with headache and anxiety
D. Peripheral cyanosis
o Answer: C
o Rationale: Patients commonly present with very high blood pressure accompanied by headache and anxiety.
- In pregnancy-related hypertensive crisis, what condition is characterized by hemolysis, elevated liver enzymes, and low platelets?
A. Gestational hypertension
B. Preeclampsia
C. HELLP syndrome
D. Eclampsia
o Answer: C
o Rationale: HELLP syndrome is a severe form of preeclampsia marked by hemolysis, elevated liver enzymes, and low platelets.
- Which of the following monitoring parameters is essential when administering magnesium sulfate?
A. Deep tendon reflexes
B. Liver enzymes
C. Blood cholesterol
D. Serum sodium levels.
o Answer: A
o Rationale: Monitoring deep tendon reflexes helps assess for magnesium toxicity
- In hypertensive crisis management, what is a common pitfall that “will harm your patient” if not carefully avoided?
A. Allowing the patient to rest before rechecking blood pressure
B. Overaggressive blood pressure lowering resulting in hypoperfusion
C. Using a blood pressure cuff that is too large
D. Measuring blood pressure in both arms
o Answer: B
o Rationale: Overly aggressive reduction in BP can precipitate organ ischemia, making careful titration critical.
- Which of the following is a recommended nonpharmacologic strategy in hypertensive crisis?
A. Encouraging strenuous exercise
B. Providing a calm, quiet environment for the patient to rest
C. Increasing dietary salt intake
D. Immediate surgical intervention
o Answer: B
o Rationale: A calm environment may help reduce anxiety-induced BP elevations and is a simple supportive measure.
- What is the potential risk of using an automated blood pressure monitor in hypertensive crisis evaluation?
A. Underestimation of heart rate
B. Overestimation of blood pressure due to incorrect cuff size or patient movement
C. Misinterpretation of respiratory rate
D. Failure to detect arrhythmias
o
Answer: B
o Rationale: Automated monitors may give inaccurate readings if the cuff is improperly sized or the patient is anxious, so manual verification is sometimes necessary.
- Which class of medications is preferred for continuous infusion in hypertensive emergencies when rapid titration is needed?
A. Oral ACE inhibitors
B. IV nicardipine or nitroprusside
C. Oral diuretics
D. Sublingual calcium channel blockers
o Answer: B
o Rationale: IV nicardipine and nitroprusside allow for rapid, controlled titration in emergencies.
- In patients with hypertensive crisis due to pain or anxiety, what supportive measure can help lower blood pressure?
A. Encouraging vigorous physical activity
B. Providing analgesia and a calm environment
C. Initiating high-dose beta agonists
D. Administering oral hyperosmolar agents
o Answer: B
o Rationale: Managing pain and anxiety can reduce sympathetic stimulation and help lower blood pressure.
- What is the expected effect of vasodilators like nitroprusside in hypertensive emergencies?
A. Increase heart rate without lowering BP
B. Reduce both preload and afterload to lower blood pressure
C. Only dilate coronary arteries
D. Exclusively reduce heart rate
o Answer: B
o Rationale: Nitroprusside dilates both arterial and venous vessels, reducing preload and afterload to lower blood pressure.
- Which laboratory or imaging study is most useful to assess for pulmonary edema in hypertensive crisis?
A. Chest X-ray
B. Abdominal ultrasound
C. CT angiography
D. Echocardiography
o Answer: A
o Rationale: A chest X-ray is the primary imaging modality for detecting pulmonary edema.
- A hypertensive crisis patient with neurological deficits should be evaluated for which acute complication?
A. Acute renal failure
B. Ischemic or hemorrhagic stroke
C. Myocardial infarction
D. Gastrointestinal bleed
o Answer: B
o Rationale: Neurological deficits in the context of hypertensive crisis warrant evaluation for stroke.
- Which of the following best describes the potential long-term consequence of repeated hypertensive crises?
A. Improved vascular compliance
B. Increased risk of cardiovascular events
C. Decreased risk for future crises
D. Enhanced renal function
o Answer: B
o Rationale: Recurrent hypertensive crises are associated with an increased incidence of long-term cardiovascular events.
- What role does close follow-up play in the management of hypertensive urgency?
A. It is unnecessary if BP is controlled in the emergency department
B. It helps ensure long-term blood pressure control and prevents progression to emergency
C. It only matters in pregnant patients
D. It is only required for patients with renal disease
o Answer: B
o Rationale: Close follow-up is essential in hypertensive urgency to ensure adherence, adjust medications, and prevent future emergencies.
- Which statement best summarizes the critical management principles for hypertensive crisis?
A. Immediate, aggressive blood pressure reduction regardless of end-organ status
B. Identification of end-organ damage, cautious blood pressure lowering (20–25% in the first 1–2 hours for emergencies), addressing underlying causes, and ensuring appropriate follow-up
C. Sole reliance on oral medications for rapid control
D. Observation without intervention if the patient is asymptomatic
o Answer: B
o Rationale: Effective management requires a balanced approach that identifies end-organ damage, uses rapid-acting, titratable IV agents to lower BP safely, and addresses the underlying causes along with appropriate follow-up.
a systolic blood pressure >180 mm Hg or diastolic >120 mm o Hypertensive crisis is characterized by a systolic blood pressure >180 mm Hg or diastolic >120 m
Hypertensive crisis is characterized by
It can occur as hypertensive urgency (without end-organ damage) or hypertensive emergency (with acute end-organ damage).
Malignant HTN
activation of the renin-angiotensin-aldosterone system and catecholamine release.
A rapid rise in blood pressure triggers
increases vascular permeability and promotes ischemia, which further amplifies vasoconstriction and end-organ damage.
Endothelial injury
o This leads to marked vasoconstriction, increased systemic vascular resistance, endothelial injury, and activation of the coagulation cascade.
catecholamine release.
Not addressing medication nonadherence or secondary causes (e.g., pheochromocytoma, renal artery stenosis, drug-induced hypertension) may lead to recurrence.
Nonadherence & Underlying Causes:
Acute injury to the brain (stroke, hypertensive encephalopathy), heart (myocardial ischemia/infarction, heart failure), and kidneys (acute kidney injury) are the most critical complications.
End-Organ Damage:
Overly aggressive blood pressure lowering risks precipitating ischemia, especially in the brain and kidneys.
Inappropriate BP Reduction
Excessively rapid blood pressure lowering can precipitate hypoperfusion and ischemia of vital organs.
Rapid Overcorrection:
Failure to identify signs of end-organ damage (e.g., neurologic deficits, pulmonary edema) can lead to missed opportunities for urgent intervention
Delayed Recognition
Using automated BP devices with improper cuff size or technique can result in inaccurate measurements and inappropriate management decisions.
Iatrogenic Errors:
High Blood Pressure Readings:
Markedly elevated BP is the hallmark.
Patients often present with headache, anxiety, chest pain, and sometimes neurologic deficits
Symptoms of End-Organ Involvement
Fundoscopic exam may reveal papilledema; careful BP measurement (including both arms) is critical.
Physical Exam Findings
Renal function tests, ECG (for ischemia), chest X-ray (for pulmonary edema), and brain imaging (for neurologic complications) are common in evaluation.
Laboratory & Imaging Evaluation:
In pregnancy, conditions like preeclampsia/eclampsia (including HELLP syndrome) are frequently encountered and require special management (e.g., IV labetalol and magnesium sulfate).
Pregnancy Considerations
Often managed with oral medications and close follow-up.
Hypertensive Urgency
Requires rapid but controlled BP reduction (targeting a 20–25% decrease within the first 1–2 hours) using IV agents (e.g., labetalol, nicardipine) while monitoring for signs of end-organ hypoperfusion.
Hypertensive Emergency
Positioning, supplemental oxygen, and addressing pain and anxiety are important nonpharmacologic interventions
Supportive Care
Ensuring adherence, addressing underlying causes, and close monitoring post-crisis to prevent recurrence are essential.
Follow-Up
