Hypertension & Hypotension — NCLEX Nursing Lesson Anatomy & Physiology · RN Track · Medical-Surgical Body Systems · Cardiovascular System · Hypertension & Hypotension Condition Lesson · NCLEX-PN / NCLEX-RN

When blood pressure runs too high (the "silent killer") or too low (a fall and perfusion risk)—and the reasoning behind every medication, diet change, and safety measure.

In this lesson

Lesson Objectives
Why This Matters
Disease Overview
Pathophysiology
Risk Factors
Signs & Symptoms
Nursing Assessment
Diagnostic Tests
Laboratory Tests
Medications
Nursing Interventions
Complications
Patient Education
Clinical Judgment
Clinical Connections
NCLEX High-Yield
Memory Aids
Case Study
Practice Questions
Key Takeaways
References

Lesson Objectives

Classify blood pressure using current categories and differentiate primary from secondary hypertension.
Explain why hypertension is the "silent killer" and how it damages the heart, brain, kidneys, eyes, and vessels.
Justify the major antihypertensive drug classes and the reasoning (and safety) behind each.
Recognize a hypertensive crisis (urgency vs. emergency) and manage hypotension (including orthostatic) with fall safety.
Apply the NCSBN Clinical Judgment model and answer NGN-style items on blood-pressure disorders.

Why This Matters

Prevalence: hypertension (HTN) is one of the most common chronic conditions—affecting nearly half of U.S. adults—and a leading cause of heart attack, stroke, heart failure, and kidney disease. Hypotension is common too, especially in older adults, dehydrated patients, and those on cardiac/BP medications. You'll manage both across every setting.

Patient safety: high BP silently damages organs for years, then causes catastrophic events (stroke, MI); a hypertensive emergency can kill within hours. Low BP causes dizziness, syncope, and falls—and, if severe, poor perfusion/shock. Managing BP safely (not too high, not dropped too fast) is core nursing.

NCLEX importance: heavily tested on BP categories, antihypertensive drug classes and safety (ACE cough, orthostatic hypotension, don't-stop-beta-blockers, potassium effects), orthostatic vital signs and fall prevention, lifestyle/DASH teaching, medication adherence, and recognizing a hypertensive crisis. It builds on the A&P of blood pressure (BP = CO × SVR) and its regulation.

Why nurses encounter it constantly: BP is checked on nearly every patient; nurses screen, medicate, teach adherence and lifestyle, and prevent falls—so both ends of the BP spectrum are daily work.

Connecting to prior lessons From A&P, recall that BP = cardiac output × systemic vascular resistance, regulated fast by baroreceptors and slower by RAAS. Hypertension = chronically high CO or SVR; hypotension = low volume, weak pump, or dilated vessels. From assessment, recall orthostatic vitals and that perfusion is the priority.

Disease Overview

Hypertension is persistently elevated arterial blood pressure. It's classified by stage:

Category	Systolic		Diastolic
Normal	<120	and	<80
Elevated	120–129	and	<80
Stage 1 HTN	130–139	or	80–89
Stage 2 HTN	≥140	or	≥90
Hypertensive crisis	>180	and/or	>120

Primary (essential) hypertension (~90–95%) has no single identifiable cause—it develops from genetics and lifestyle. Secondary hypertension results from another condition (kidney disease, endocrine disorders, sleep apnea, certain drugs). Hypotension is low blood pressure (generally <90/60) that causes symptoms or poor perfusion; orthostatic (postural) hypotension is a drop on standing.

Analogy — the garden hose

Think of the arteries as a garden hose. Hypertension is like running the water at too much pressure—over years it wears out and stiffens the hose and strains the pump (heart), and it can burst a weak spot (aneurysm/stroke). Hypotension is too little pressure—the water can't reach the far end of the garden (the brain and organs), so the plants wilt (dizziness, fainting, poor perfusion). The nurse's job is to keep the pressure in the just-right range—and to lower a dangerously high pressure gradually, not all at once.

Pathophysiology

Normal physiology: BP = cardiac output × systemic vascular resistance, kept stable by baroreceptors (fast) and RAAS/hormones (slow). Healthy vessels dilate and constrict to match demand. ↓ Hypertension: over time, increased vessel tone/stiffness and/or fluid volume raise SVR and CO → the heart pumps against higher resistance → chronic high pressure damages the inner lining of arteries (atherosclerosis) and forces the left ventricle to thicken (hypertrophy). ↓ How symptoms appear: HTN is usually asymptomatic ("silent killer")—damage accumulates quietly. Symptoms (headache, vision changes) appear only when BP is very high or organs are affected. ↓ How it progresses: years of high pressure damage target organs → heart (MI, heart failure, LVH), brain (stroke), kidneys (chronic kidney disease), eyes (retinopathy), and vessels (aneurysm/PAD). A sudden severe spike is a hypertensive crisis. ↓ Hypotension: low volume (bleeding/dehydration), a weak pump (bradycardia/MI), dilated vessels (sepsis, medications), or autonomic failure → BP falls → organs (especially the brain) are underperfused → dizziness, syncope, and (if severe) shock. NCLEX Clinical Pearl — why HTN is the "silent killer" Most people with hypertension feel fine—there are usually no symptoms until organ damage is advanced or a crisis hits. That's why screening, adherence, and lifestyle change matter even when the patient feels well, and why "I feel okay, so I stopped my pills" is a dangerous (and classic NCLEX) mistake.

Risk Factors

Non-modifiable	Modifiable	Preventable / reducible
Age (risk rises with age) Family history/genetics Race/ethnicity (higher HTN prevalence/severity in Black adults) Male sex (earlier onset)	High sodium diet, obesity, physical inactivity Excess alcohol, smoking Chronic stress Uncontrolled diabetes/sleep apnea	DASH diet & sodium reduction Weight loss, regular exercise Limiting alcohol, smoking cessation Stress management; treating sleep apnea

High-risk populations (HTN): older adults, Black adults, people with obesity/diabetes/kidney disease/sleep apnea, and those with a family history. High-risk for hypotension: older adults, the dehydrated or bleeding, patients on antihypertensives/diuretics/nitrates, those on prolonged bed rest, and people with autonomic dysfunction (e.g., Parkinson's, diabetes).

Signs & Symptoms

Category	Findings & WHY they occur
Hypertension — early/expected	Usually asymptomatic. When present: headache (often occipital, worse in the morning), dizziness, or vision changes—from elevated pressure. Screening BP is often the only clue.
Hypertension — late	Signs of target-organ damage: chest pain/dyspnea (heart), neuro deficits (stroke), decreased urine/edema (kidney), retinal changes (eyes), and left ventricular hypertrophy.
Hypertensive crisis (emergency)	Severe BP >180/120 WITH signs of organ damage: severe headache, blurred vision, confusion, chest pain, dyspnea, seizures, or focal neuro deficits. This is a medical emergency.
Hypotension	Dizziness, lightheadedness, blurred vision, weakness/fatigue, and syncope (fainting)—the brain isn't perfused. Cool, clammy skin and confusion suggest severe/shock.
Orthostatic hypotension	Dizziness/lightheadedness on standing; a drop of ≥20 mm Hg systolic or ≥10 mm Hg diastolic within 3 minutes of standing (± a big HR rise). A major fall risk.
Emergency findings	Hypertensive emergency (very high BP + organ signs) or severe hypotension with poor perfusion/shock (cool, clammy, altered mentation, weak pulses).

Why lowering BP too fast is dangerous In a hypertensive emergency, BP must be lowered gradually and carefully (per protocol), not slammed to normal. Dropping it too fast can cause cerebral, cardiac, or kidney ischemia because those organs have adapted to the higher pressure. Controlled reduction protects the very organs you're trying to save.

Nursing Assessment

Subjective: headache, dizziness, vision changes, chest pain/dyspnea, syncope/near-fainting, medication list and adherence, diet/sodium/alcohol, stress, and symptoms on standing (orthostatic).

Objective: blood pressure with correct technique (right cuff size, both arms if indicated, orthostatic vitals if dizzy/at risk), heart rate/rhythm, perfusion, edema, heart/lung sounds, neuro status, and signs of target-organ damage.

Priority / focused finding	Why it matters / action
BP reading & trend	Confirm with correct technique; a crisis (>180/120) needs escalation, especially with symptoms.
Organ-damage signs (crisis)	Chest pain, neuro deficits, severe headache/vision changes = emergency—notify immediately.
Orthostatic changes / fall risk	A significant drop on standing = fall risk—institute precautions.
Perfusion (hypotension)	Cool, clammy, altered mentation, weak pulses = poor perfusion/shock—escalate.
Medication response/adherence	Guides safe titration and teaching.

When to notify / act now BP >180/120 (especially with headache, chest pain, neuro/vision changes, or dyspnea = hypertensive emergency), severe hypotension with poor perfusion/altered mentation, syncope, or a significant new orthostatic drop. These need prompt escalation.

Diagnostic Tests

Test	Purpose / why ordered	Findings & nursing considerations
Serial/ambulatory BP monitoring	Confirm diagnosis (avoid "white-coat" over-reading) and track control	Use correct technique; diagnosis needs multiple elevated readings. Teach home monitoring.
ECG	Detect left ventricular hypertrophy, ischemia, or dysrhythmia	LVH suggests long-standing HTN; ischemia/MI in crisis.
Echocardiogram	Assess heart structure/function (hypertrophy, heart failure)	Noninvasive; evaluates target-organ effects.
Workup for secondary causes (renal ultrasound, hormone studies)	Find a treatable cause when HTN is severe/young/resistant	Guides specific treatment.
Fundoscopic (eye) exam	Detect hypertensive retinopathy/papilledema	Papilledema signals a hypertensive emergency.

Laboratory Tests

Test	Normal / expected	Significance
Basic metabolic panel — potassium	K⁺ 3.5–5.0 mEq/L	Diuretics can lower K⁺ (thiazide/loop) or ACE/ARB/spironolactone can raise it—monitor closely (dysrhythmia risk).
BUN / creatinine (kidney function)	BUN 10–20; Cr 0.6–1.2 mg/dL	HTN damages kidneys; monitor before/with ACE/ARB and diuretics.
Lipid panel	LDL <100 mg/dL (lower if high-risk)	Assesses cardiovascular risk (HTN + hyperlipidemia compound risk).
Blood glucose / A1C	Fasting 70–110; A1C <5.7%	Diabetes worsens vascular risk; often coexists.
CBC (H&H)	Hgb 12–17 g/dL	In hypotension, a low H&H points to bleeding as the cause.

Trend interpretation Watch potassium closely with BP drugs—thiazide/loop diuretics lower it; ACE inhibitors, ARBs, and potassium-sparing diuretics (spironolactone) raise it. Abnormal K⁺ causes dangerous dysrhythmias. Also trend renal function (BUN/Cr) with ACE/ARB/diuretics, and H&H in hypotension (bleeding).

Medications (Antihypertensives)

Diuretics

Type / drug	Mechanism & key nursing/teaching
Thiazide — hydrochlorothiazide (often first-line)	Excrete sodium/water → lower volume. Lose potassium (monitor K⁺); give in the morning; watch for orthostatic hypotension; sulfa allergy caution.
Loop — furosemide	Stronger diuresis (also for heart failure). Lose potassium (and can be ototoxic in high doses); monitor electrolytes/volume.
Potassium-sparing — spironolactone	Save potassium while removing fluid. Risk of hyperkalemia—avoid extra K⁺/salt substitutes; watch for gynecomastia.

ACE inhibitors (-pril) & ARBs (-sartan)

Mechanism/why: block the RAAS to relax vessels and reduce fluid retention. ACE inhibitors (lisinopril, enalapril): watch for a persistent dry cough, angioedema, hyperkalemia, and first-dose hypotension. ARBs (losartan, valsartan): similar but no cough (used when ACE causes cough); still cause hyperkalemia. Both are teratogenic—avoid in pregnancy. Monitor potassium and renal function.

Calcium channel blockers

Amlodipine (dihydropyridine) relaxes vessels (watch peripheral edema); diltiazem/verapamil also slow the heart rate (watch bradycardia; verapamil → constipation). Avoid grapefruit juice (raises drug levels). Monitor HR/BP.

Beta-blockers (-olol)

Metoprolol, atenolol, carvedilol: reduce heart rate and contractility (lower CO). Caution in asthma/COPD (bronchospasm), can mask hypoglycemia symptoms in diabetics, cause bradycardia/fatigue, and must not be stopped abruptly (rebound hypertension/tachycardia). Hold for low HR per parameters.

Others & crisis medications

Purpose	Agent & nursing
Central agonists	Clonidine—do not stop abruptly (rebound HTN); causes sedation/dry mouth.
Direct vasodilators	Hydralazine (reflex tachycardia); minoxidil.
Alpha-blockers (-osin)	Prazosin, doxazosin—first-dose orthostatic hypotension; take at bedtime.
IV for hypertensive emergency	Nitroprusside, labetalol, nicardipine—titrate carefully with continuous monitoring; lower BP gradually.

Safety — orthostatic hypotension & adherence Nearly all antihypertensives can cause orthostatic hypotension—teach patients to change positions slowly and use fall precautions. And teach that BP meds are usually lifelong and taken daily even when feeling fine; never stop beta-blockers or clonidine abruptly (rebound effects). NCLEX testing points Thiazide/loop diuretics → low K⁺; ACE/ARB/spironolactone → high K⁺. ACE inhibitors → dry cough & angioedema (switch to ARB). Beta-blockers → don't stop abruptly, caution in asthma, mask hypoglycemia. CCBs → avoid grapefruit; watch edema/bradycardia. All → orthostatic hypotension. Lower a crisis BP gradually.

Nursing Interventions

Priority	Intervention & WHY
Airway/Breathing	Usually intact—but in a hypertensive emergency (pulmonary edema, stroke) or severe hypotension/shock, support oxygenation and monitor closely.
Circulation (the focus)	Monitor BP with correct technique and trends; in a crisis, titrate IV antihypertensives to lower BP gradually; in hypotension, give fluids/hold offending meds and support perfusion.
Safety (top priority)	Fall precautions for orthostatic hypotension—teach slow position changes, assist with ambulation, keep the call light in reach; monitor for dizziness/syncope.
Medication administration	Give antihypertensives correctly; check BP/HR against parameters before dosing; monitor potassium/renal function; never abruptly stop beta-blockers/clonidine.
Comfort	Calm environment, headache/symptom relief, and stress reduction (stress raises BP).
Patient education	DASH/low-sodium diet, weight/exercise, adherence, home BP monitoring, orthostatic precautions, and warning signs.
Fluid/volume (hypotension)	Encourage fluids (if not contraindicated), position supine/legs up for acute drops, and identify/treat the cause (bleeding, meds, sepsis).
Interdisciplinary	Provider/cardiology, dietitian (DASH), pharmacy (med review), and social work for adherence support.

Why lifestyle change is real treatment Reducing sodium, losing weight, exercising, and limiting alcohol can lower BP as much as a medication—and reduce the number/dose of drugs needed. The DASH diet (rich in fruits, vegetables, whole grains, and low-fat dairy; low in sodium and saturated fat) is proven to lower blood pressure. Teaching it is powerful, evidence-based nursing.

Potential Complications

Complication	Early signs	Nursing / emergency response
Hypertensive emergency	BP >180/120 with severe headache, chest pain, vision changes, confusion, dyspnea	Emergency: continuous monitoring, IV antihypertensives titrated to lower BP gradually, notify provider; protect organs.
Stroke	Sudden weakness, facial droop, speech changes, severe headache	Emergency: activate stroke protocol; time-critical.
MI / heart failure	Chest pain, dyspnea, crackles, edema	Oxygen, ECG, notify provider; treat per protocol.
Kidney damage	Rising creatinine, decreased urine, edema	Monitor renal function; adjust meds; manage fluid.
Falls/injury (hypotension)	Dizziness, syncope, orthostatic drop	Fall precautions, slow position changes, treat cause.
Shock (severe hypotension)	Cool clammy skin, altered mentation, weak pulses	Emergency: fluids/vasopressors, oxygen, treat cause; escalate.

Patient Education

Disease process: explain that hypertension is usually symptom-free but dangerous—control protects the heart, brain, and kidneys. Lifestyle modifications: follow the DASH diet and reduce sodium, lose weight, exercise regularly, limit alcohol, stop smoking, and manage stress. Medication adherence: take BP medications every day, even when feeling well—never stop abruptly (especially beta-blockers/clonidine); understand common effects (ACE cough, dizziness) and report them rather than quitting; watch potassium/salt substitutes with certain drugs. Home care: monitor BP at home with correct technique and keep a log; change positions slowly (orthostatic precautions). Follow-up: keep appointments and lab checks (potassium, kidney function). Warning signs / when to seek emergency care: a very high BP with severe headache, chest pain, vision changes, confusion, one-sided weakness/speech trouble, or fainting—seek emergency care. For hypotension: report frequent dizziness/fainting.

Clinical Judgment (NCSBN Model)

Recognize cues: a patient with hypertension presents with a BP of 212/124, a severe pounding headache, blurred vision, and new confusion; he admits he "stopped taking my blood pressure pills a few weeks ago because I felt fine."
Analyze cues: severe BP >180/120 with neuro/vision symptoms = a hypertensive emergency (target-organ involvement), likely triggered by medication nonadherence. This is life-threatening.
Prioritize hypotheses: hypertensive emergency with possible neurologic injury—controlled BP reduction and organ protection are the priority.
Generate solutions: continuous BP/cardiac/neuro monitoring, IV antihypertensives titrated to lower BP gradually (not to normal too fast), oxygen if needed, quiet environment, notify the provider/Rapid Response, and prepare for further workup.
Take action: establish IV access, begin the ordered titrated antihypertensive, monitor closely, and reassess neuro status frequently.
Evaluate outcomes: is BP coming down at a safe, controlled rate and are symptoms improving without new deficits? Reinforce adherence teaching (why to take meds even when feeling fine) at discharge.

Clinical Connections — commonly confused conditions

	Hypertension	Hypotension	Orthostatic hypotension
Cause	Chronically high BP (↑ CO/SVR)	Low volume, weak pump, or dilated vessels	Failure to compensate on standing (volume/meds/autonomic)
Hallmark	Often asymptomatic; screening BP high	Dizziness, syncope, poor perfusion	Drop ≥20 systolic / ≥10 diastolic on standing with dizziness
Diagnostics	Serial BP, ECG/echo, organ workup	BP, cause workup (H&H, cause)	Orthostatic vital signs
Treatment	Lifestyle + antihypertensives	Fluids, treat cause, hold offending meds	Slow position changes, fluids, adjust meds
Priority nursing	Adherence, lifestyle, prevent organ damage	Perfusion, safety, treat cause	Fall prevention

	Hypertensive urgency	Hypertensive emergency
BP	>180/120	>180/120
Organ damage	No acute target-organ damage	Yes—stroke, MI, encephalopathy, papilledema, kidney injury
Treatment	Oral meds; lower over hours–days	IV meds; lower gradually with monitoring

Key discriminators: hypertension is usually silent; hypotension causes dizziness/poor perfusion; orthostatic hypotension is a drop on standing (fall risk). Hypertensive emergency = very high BP plus organ damage.

NCLEX High-Yield Review

What the NCLEX Wants You to Know

HTN is the "silent killer" Take meds even when feeling fine; adherence is everything.
Diuretics: thiazide/loop lose K⁺; spironolactone/ACE/ARB raise K⁺ Monitor potassium.
ACE = dry cough/angioedema; beta-blockers = don't stop abruptly
Orthostatic drop ≥20/≥10 on standing Fall precautions; change positions slowly.
Lower a hypertensive emergency GRADUALLY Too fast → organ ischemia.

Common distractors: stopping BP meds "because I feel fine," stopping a beta-blocker/clonidine abruptly, lowering a crisis BP to normal too fast, giving potassium/salt substitutes with ACE/ARB/spironolactone, and ignoring orthostatic drops. Priority interventions: recognize a hypertensive emergency, control BP gradually, fall safety for hypotension, medication safety, and teaching. Expected vs unexpected: asymptomatic elevated BP is common; a BP >180/120 with headache/chest pain/neuro changes, or severe hypotension with poor perfusion, are emergencies. Patient teaching: DASH/low sodium, adherence, orthostatic precautions, home BP monitoring, ACE cough. Safety: orthostatic falls, potassium, holding meds per parameters. Delegation: RN assesses/interprets and manages crises/emergencies; UAP can take BP (correct technique), assist with slow position changes/ambulation, and report readings/dizziness—but not interpret or titrate meds. Frequently tested meds: HCTZ, furosemide, spironolactone, lisinopril/losartan, amlodipine, metoprolol, clonidine. Critical values: potassium, BUN/Cr, BP thresholds. Most common mistakes: nonadherence, abrupt beta-blocker/clonidine stop, and rapid BP lowering in a crisis.

Memory Aids

HTN = "Silent killer" — usually no symptoms; screen and treat anyway.
Potassium "Loops/Thiazides Lose it; ACE/ARB/Spironolactone Keep it."
ACE inhibitors "the 3 C's": Cough, ang-C-oedema (angioedema), and hyper-K (careful K⁺) — switch to an ARB for the cough.
Beta-blockers "-olol, don't stop it all at once" — rebound HTN/tachycardia; caution in asthma; mask hypoglycemia.
Orthostatic "20/10 within 3" — ≥20 systolic or ≥10 diastolic drop within 3 minutes of standing.
DASH diet = "Dietary Approaches to Stop Hypertension" — fruits/veg/whole grains, low sodium.
Crisis "lower slow, save the organs."

Case Study — from admission to discharge

Admission. Mr. Reyes, 58, with a history of hypertension, comes to the ED with a severe pounding headache, blurred vision, and a "nosebleed that won't stop." BP is 208/122, HR 96. He mentions he "ran out of my pills two weeks ago and figured I was fine since I felt okay." He is anxious; neuro exam is intact but he's mildly confused.

Step 1–2: Recognize & analyze cues

Cues: BP >180/120 with severe headache, blurred vision, epistaxis, and mild confusion = hypertensive emergency (target-organ symptoms), triggered by medication nonadherence.

Step 3–4: Prioritize & plan

Priority: controlled BP reduction and organ protection. Plan: continuous BP/cardiac/neuro monitoring, IV access, IV antihypertensive titrated to lower BP gradually, quiet calm environment, control the nosebleed (lean forward, pressure), and reassess neuro status frequently; notify the provider.

Step 5: Take action

The nurse starts continuous monitoring and the ordered titrated IV antihypertensive (e.g., nicardipine/labetalol), lowering BP gradually (not to normal too quickly), manages the epistaxis, keeps the environment calm, and monitors neuro status and urine output.

Step 6: Evaluate & discharge

BP comes down safely, the headache and confusion resolve, and no new deficits develop. He's transitioned to oral medications. Discharge teaching: take BP medications every day even when feeling fine (this is why he ended up here), never stop abruptly, follow a low-sodium/DASH diet, monitor BP at home, change positions slowly, keep follow-up/lab appointments, and seek emergency care for severe headache, chest pain, vision changes, weakness, or confusion.

NCLEX Practice Questions

Answer choices are numbered; the correct answer is given as a number.

1. A client with hypertension says, "I feel fine, so I stopped taking my blood pressure medicine." What is the nurse's best response?

"That's reasonable since your blood pressure is probably normal now."
"You can stop the medicine whenever you feel well."
"Hypertension usually has no symptoms; the medicine protects your organs even when you feel fine, so keep taking it."
"Only restart it if you get a headache."

Rationale

Answer: 3. Hypertension is the "silent killer"—usually symptom-free—so medication and lifestyle must continue even when feeling well to prevent organ damage. Stopping (1, 2) or waiting for symptoms (4) is dangerous.

2. A client taking lisinopril (an ACE inhibitor) develops a persistent dry cough. The nurse anticipates the provider may:

Switch the client to an ARB (e.g., losartan)
Add a potassium supplement
Double the lisinopril dose
Restrict all fluids

Rationale

Answer: 1. A persistent dry cough is a classic ACE-inhibitor side effect; switching to an ARB (which doesn't cause cough) is common. Adding potassium (2) is dangerous with ACE/ARB (hyperkalemia risk), and doubling the dose (3) or restricting fluids (4) doesn't address the cough.

3. A client is prescribed hydrochlorothiazide. Which laboratory value is most important for the nurse to monitor?

Blood glucose only
Platelet count
White blood cell count
Serum potassium

Rationale

Answer: 4. Thiazide (and loop) diuretics cause potassium loss (hypokalemia), which can trigger dysrhythmias—monitor serum potassium. The other values are not the priority concern with thiazides.

4. When assessing for orthostatic hypotension, the nurse identifies a positive finding as a drop in:

Systolic ≥40 mm Hg only
Systolic ≥20 mm Hg or diastolic ≥10 mm Hg within 3 minutes of standing
Diastolic ≥30 mm Hg only
Any change in heart rate

Rationale

Answer: 2. Orthostatic hypotension is a drop of ≥20 mm Hg systolic or ≥10 mm Hg diastolic within 3 minutes of standing (often with symptoms/HR rise). The other thresholds are incorrect.

5. A client with a hypertensive emergency has a BP of 220/126. Which principle guides the nurse's care?

The BP must be lowered to normal within a few minutes
No treatment is needed if the client feels well
The BP should be lowered gradually and in a controlled manner
Oral medications alone are always sufficient

Rationale

Answer: 3. In a hypertensive emergency, BP is lowered gradually with titrated IV medications and monitoring—dropping it too fast (1) causes cerebral/cardiac/renal ischemia. It always needs treatment (2), and emergencies typically require IV therapy (4).

6. SATA. Which teaching points are appropriate for a client starting antihypertensive therapy? Select all that apply.

Change positions slowly to prevent dizziness
Take the medication daily, even when feeling well
Stop a beta-blocker suddenly if you feel better
Follow a low-sodium/DASH diet
Monitor blood pressure at home and keep a log

Rationale

Answers: 1, 2, 4, 5. Slow position changes, daily adherence, DASH/low-sodium diet, and home BP monitoring support safe, effective control. Stopping a beta-blocker suddenly (3) causes rebound hypertension/tachycardia and is dangerous.

7. SATA. Which findings indicate a hypertensive emergency requiring immediate action? Select all that apply.

BP 184/122 with a severe headache
New confusion and blurred vision
BP 128/78 with no symptoms
Chest pain and shortness of breath
One-sided weakness and slurred speech

Rationale

Answers: 1, 2, 4, 5. Very high BP with organ-related symptoms (headache, confusion/vision changes, chest pain/dyspnea, neuro deficits) signals a hypertensive emergency. A normal BP with no symptoms (3) is not an emergency.

8. Priority. A nurse is caring for four clients. Who should be assessed first?

A client with a BP of 220/124 reporting a severe headache and blurred vision
A client with well-controlled hypertension requesting diet teaching
A client with a BP of 132/84 awaiting discharge
A client asking about home BP monitoring

Rationale

Answer: 1. A BP of 220/124 with a severe headache and blurred vision indicates a hypertensive emergency (target-organ signs)—an immediate priority. The others are stable or routine.

9. Delegation. Which task can the RN appropriately delegate to unlicensed assistive personnel (UAP) for a stable client on antihypertensive therapy?

Interpreting the blood-pressure trend
Teaching about the DASH diet
Titrating the IV antihypertensive drip
Obtaining orthostatic blood pressures using correct technique and reporting the readings

Rationale

Answer: 4. Taking BP (including orthostatics) with correct technique and reporting readings is within UAP scope. Interpreting trends (1), teaching (2), and titrating IV drips (3) require the licensed nurse.

10. NGN Case Study. A 72-year-old on a thiazide diuretic and lisinopril is admitted after a fall at home. She reports dizziness when standing. Vitals lying: 128/76, HR 74. Standing: 102/60, HR 96, with lightheadedness. Labs: potassium 3.2 mEq/L.

a) What problems do these cues reveal?
b) What are the priority nursing actions and teaching?

Model answer

a) Problems: orthostatic hypotension (a drop of 26 systolic/16 diastolic with symptoms and a HR rise on standing) causing a fall, plus hypokalemia (K⁺ 3.2) from the thiazide. Both raise safety and dysrhythmia risk in an older adult on antihypertensives.

b) Priority actions/teaching: 1) fall precautions—teach slow position changes (sit before standing), assist with ambulation, call light in reach; 2) notify the provider about the orthostatic drop and low potassium—anticipate potassium replacement and possible medication adjustment; 3) recheck orthostatic vitals and monitor for symptoms; 4) encourage adequate fluids (as appropriate) and review the medication regimen; 5) teach that BP meds cause dizziness on standing and to report it rather than stop the medication. Evaluate that she remains fall-free, potassium normalizes, and orthostatic symptoms improve.

Key Takeaways

Hypertension is the "silent killer"—usually symptom-free but it damages the heart, brain, kidneys, eyes, and vessels; adherence and lifestyle matter even when feeling fine.
Know the categories (Normal <120/80; Stage 1 130–139/80–89; Stage 2 ≥140/≥90; crisis >180/120) and primary vs. secondary HTN.
Diuretics: thiazide/loop lose potassium; ACE/ARB/spironolactone raise it—monitor K⁺. ACE → dry cough/angioedema (switch to ARB). Beta-blockers → don't stop abruptly, caution in asthma, mask hypoglycemia.
All antihypertensives can cause orthostatic hypotension—teach slow position changes and use fall precautions.
Hypertensive emergency (BP >180/120 + organ symptoms) → lower BP gradually with IV meds and monitoring; too fast causes organ ischemia.
Hypotension (low volume/weak pump/dilated vessels) → dizziness, syncope, falls, and possibly shock; ensure safety, fluids, and treat the cause. Orthostatic = drop ≥20 systolic/≥10 diastolic on standing.
Lifestyle is real treatment: DASH diet, low sodium, weight loss, exercise, limit alcohol, stop smoking.

References

Hinkle, J. L., Cheever, K. H., & Overbaugh, K. J. (2022). Brunner & Suddarth's textbook of medical-surgical nursing (15th ed.). Wolters Kluwer/Lippincott.
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2021). Medical-surgical nursing: Concepts for interprofessional collaborative care (10th ed.). Elsevier.
Silvestri, L. A., & Silvestri, A. E. (2023). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier.
Assessment Technologies Institute. (2023). ATI RN adult medical-surgical nursing review module (12th ed.). ATI Nursing Education.
Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison Himmelfarb, C., … Wright, J. T. (2018). 2017 ACC/AHA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Hypertension, 71(6), e13–e115. https://doi.org/10.1161/HYP.0000000000000065
American Heart Association. (2024). Understanding blood pressure readings & hypertensive crisis. https://www.heart.org
Centers for Disease Control and Prevention. (2024). High blood pressure (hypertension). U.S. Department of Health and Human Services. https://www.cdc.gov/bloodpressure
National Heart, Lung, and Blood Institute. (2023). DASH eating plan. National Institutes of Health. https://www.nhlbi.nih.gov

Hypertension & Hypotension

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Wellness Center

Nursing Foundations

Fundamentals & Safety

Pharmacology

Dosage Calculations

Leadership, Management & Delegation

Medical-Surgical Body Systems

Neurological System

Sensory System

Endocrine System

Respiratory System

Cardiovascular System

Hematologic/Immune/Lymphatic System

Gastrointestinal (GI) System

Renal & Genitourinary

Reproductive System

Musculoskeletal System

Integumentary System

Specialty Areas

Maternity

Infectious Diseases

Pediatrics

Mental Health

NCLEX Success Center

Clinical Judgment Practice

Prioritization Practice

Delegation Practice

Lab Values

Final Review