Hypertension and Hypertensive Emergency

Medical-Surgical · Cardiovascular·Updated 2026-10-27

What it is

Hypertension is a sustained arterial pressure that damages vessel walls in the brain, heart, kidneys, eyes and peripheral arteries. A hypertensive crisis is a systolic pressure above 180 mm Hg and/or a diastolic pressure above 120 mm Hg; it is an emergency when acute target organ damage is present (encephalopathy, stroke, MI, aortic dissection, pulmonary edema, acute kidney injury). Cerebral autoregulation has adapted to the high pressure, so lowering it too fast causes cerebral, coronary and renal ischemia.

What the NCLEX focuses on

Accurate measurement: client seated with back supported, feet flat, arm at heart level, correct cuff size, no caffeine, smoking or exercise for 30 minutes before.
In a crisis, the priority assessment is neurologic: level of consciousness, headache, visual change, focal deficits.
IV agents (nicardipine, clevidipine, labetalol, esmolol, sodium nitroprusside) are titrated with continuous BP monitoring; nitroprusside causes cyanide toxicity.
Aortic dissection is the exception that needs faster lowering of pressure.
Over-the-counter decongestants (pseudoephedrine, phenylephrine) and NSAIDs raise blood pressure.
Drug effects: ACE inhibitors (cough, angioedema, hyperkalemia), thiazides (hypokalemia), beta blockers (bradycardia), all classes (orthostatic hypotension).
Nonadherence is common because hypertension causes no symptoms.

Priority nursing actions

Assess neurologic status, chest pain, dyspnea and urine output.
Confirm the reading with a correctly sized cuff and start continuous cardiac and BP monitoring (arterial line in ICU).
Establish IV access and titrate the prescribed IV antihypertensive to the MAP goal.
Check neurologic status and hourly urine output during titration.
Report new chest pain, neurologic change or a pressure drop below the goal.

Numbers to know

Category	Systolic / diastolic (mm Hg)	Why it matters
Normal	Below 120 and below 80	Recheck yearly
Elevated	120 to 129 and below 80	Lifestyle change
Stage 1	130 to 139 or 80 to 89	Lifestyle change; drugs based on risk
Stage 2	140 or higher or 90 or higher	Lifestyle change plus medication
Hypertensive crisis	Above 180 and/or above 120	Assess for target organ damage
Emergency, first hour	Lower MAP by no more than 25%	Prevents cerebral and coronary ischemia
Next 2 to 6 hours	Toward 160/100 to 110	Then to normal over 24 to 48 hours
Sodium intake	Ideal below 1,500 mg/day	Lowers blood pressure

Common exam traps

Choosing to normalize BP within the first hour: wrong because rapid lowering causes stroke, MI and kidney injury.
Choosing to agree that pills can be skipped when the client feels fine: wrong because hypertension is silent; explore the reasons for nonadherence.
Choosing a decongestant for nasal congestion: wrong because sympathomimetics raise blood pressure.
Choosing a small cuff on a large arm: wrong because it gives a falsely high reading.

What to teach

Follow the DASH eating plan: vegetables, fruit, whole grains, low-fat dairy, fish, poultry and legumes; read labels for sodium.
Limit alcohol to 2 drinks a day for men and 1 for women; stop smoking; stay active and reach a healthy weight.
Take home readings with a validated cuff and keep a log; rise slowly.
Report severe headache, chest pain, vision change or weakness at once.

Client handout: High Blood Pressure (Hypertension) Self-Care (nurse guide and printable patient handout).

Try 2 NCLEX-style questions on this topic

From the NCLEXPace question bank. Pick your answers, then check them inside NCLEXPace.

Question 1 · QID 45CB66D5

A client with confusion and blurred vision has a blood pressure of 224/132 mm Hg. The provider prescribes an intravenous sodium nitroprusside infusion. To avoid lowering blood pressure too rapidly, which approximate mean arterial pressure should be the lowest initial goal?

Select the best answer.

A. 85 mm Hg
B. 105 mm Hg
C. 145 mm Hg
D. 122 mm Hg

Question 2 · QID E97EFBC0

The nurse teaches a client with hypertension about the Dietary Approaches to Stop Hypertension (DASH) eating plan. Which client statements demonstrate understanding? Select all that apply.

A. “I will eat more vegetables, fruit, and whole grains.”
B. “I will replace many red-meat meals with fish, poultry, beans, or lentils.”
C. “I can choose low-fat milk or yogurt as part of the plan.”
D. “Removing the salt shaker is enough; I do not need to read food labels.”
E. “I will replace salty chips with fresh fruit or unsalted nuts.”
F. “Sugary drinks and sweets should make up a large part of my daily calories.”

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Sources

Harding MM, Kwong J, Hagler D, Reinisch C. Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 12th ed. Elsevier; 2023; Chapter: Hypertension.
Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension. 2018;71(6):e13-e115.
Jones DW, et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults. Hypertension. 2025;82(10):e212-e316.

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