A nurse is assessing a 22-year-old male client admitted to the psychiatric unit with suspected anorexia nervosa. Which assessment finding would be most indicative of the severity of the client's condition and require immediate nursing intervention?
1Body mass index (BMI) of 16.5 kg/m² with recent weight loss of 2 kg per week
2Amenorrhea for the past 8 months with low estrogen levels
3Reports of consuming only 400 calories per day with daily purging
4Heart rate of 45 beats per minute with irregular rhythm✓ 정답
해설
Bradycardia with irregular rhythm indicates severe cardiovascular compromise requiring immediate intervention. Other findings are concerning but less immediately life-threatening.
Clinical Judgment
This question evaluates your ability to determine the severity of a patient with Anorexia Nervosa and prioritize immediate nursing interventions. The key is to identify the finding that indicates the most immediate threat to life, marked by Notify HCP!. While all options are typical findings of the disease, the Critical Cue is cardiovascular instability. A heart rate of 45 beats/min and an irregular rhythm signify severe bradycardia and arrhythmia, which is an emergency that can lead to cardiac arrest. This is a sign of myocardial damage due to severe malnutrition and electrolyte imbalances (especially hypokalemia and hypophosphatemia), requiring immediate medical intervention.
Memory Tip:
Cardiac comes First! When assessing eating disorders, remember the basic principle of ABCs (Airway, Breathing, Circulation). Bradycardia and Irregular rhythm are signs of a Big Issue.
KR vs US:
In Korea, a heart rate of 45 beats/min might be found in athletes and could be evaluated differently depending on the context, but in the US NGN/NCLEX context, bradycardia and irregular rhythm in a patient with Anorexia Nervosa are always considered the highest-risk signal. In Korean clinical practice, this might be judged comprehensively alongside electrolyte levels, but the exam asks about the absolute priority for life-threatening signs.
Clinical Practice Guide
The initial evaluation of patients with anorexia nervosa focuses on screening for life-threatening complications. Use the CAGE tool (heart rate, blood pressure, temperature, electrolytes).
1Cardiovascular systemMonitor for bradycardia (HR <50), hypotension, orthostatic hypotension, and QT interval prolongation.
2Metabolic/ElectrolytesRegularly check for hypophosphatemia (risk of Refeeding Syndrome), hypokalemia, and hypomagnesemia.
3Weight and NutritionBMI is an important indicator, but it is not the sole criterion for determining acute life-threatening risk.
Caution:
In SATA (Select All That Apply) questions, when choosing the "highest priority" or "must be reported immediately" items, do not confuse objective findings that threaten physiological stability (especially cardiac) with subjective symptoms/behaviors reported by the patient. For example, very low caloric intake is serious, but it is a 'cause' rather than an already occurring cardiac complication, and its ranking differs in terms of the urgency of intervention.
Anorexia Nervosa — Anorexia nervosa. A serious eating disorder characterized by an extreme fear of weight gain, distorted body image, and severe dietary restriction.
Bradycardia — Bradycardia. In adults, a resting heart rate of less than 60 beats per minute. In anorexia nervosa, it occurs due to malnutrition and reduced sympathetic nervous system activity, and can be life-threatening.
Amenorrhea — Amenorrhea. A condition where menstruation is absent for three or more consecutive cycles, or where menstruation has not begun after pubertal development. A common endocrine complication in anorexia nervosa.
Body Mass Index — Body mass index. Weight (kg) divided by the square of height (m). In adults, less than 18.5 is classified as underweight.
Refeeding Syndrome — Refeeding syndrome. A life-threatening electrolyte shift (especially a sharp drop in blood levels of phosphorus, potassium, and magnesium) and fluid imbalance that can occur when nutrition is rapidly supplied in a state of severe malnutrition.