A nurse is assessing a 19-year-old female 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?

Bradycardia with irregular rhythm indicates severe cardiovascular compromise requiring immediate intervention. Other findings are concerning but less immediately life-threatening.

Core Nursing Explanation Key Concept Analysis: This question tests the ability to prioritize life-threatening complications in a patient with Anorexia Nervosa (AN). While all findings are serious, the nurse must identify the finding that signals immediate physiological instability and risk of sudden cardiac death. The pathophysiology involves severe malnutrition leading to catabolism of body tissues, including the heart muscle. The body enters a state of metabolic adaptation to conserve energy, which depresses vital functions, but this adaptation has dangerous limits.

Answer Rationale: Key Point! A heart rate of 45 beats per minute (bradycardia) with an irregular rhythm is the most critical finding. This indicates severe cardiovascular compromise. The heart muscle is weakened (cardiomyopathy), and electrolyte imbalances (especially hypokalemia, hypomagnesemia, hypophosphatemia) disrupt the heart's electrical conduction system. This combination can lead to fatal arrhythmias like torsades de pointes or asystole. This requires immediate intervention such as cardiac monitoring, electrolyte correction, and potentially transfer to a medical unit.

Distractor Analysis:

• Option 1 (BMI of 16.5 kg/m²): A BMI of 16.5 falls into the "underweight" category (normal is 18.5-24.9) and is a diagnostic criterion for AN. While it indicates severity, it is a static measurement and does not by itself indicate an acute, life-threatening crisis.
• Option 2 (Amenorrhea for 8 months): Amenorrhea (absence of menstruation) is a key diagnostic criterion due to hypothalamic-pituitary axis suppression from low body fat and energy deficit. It signifies chronic severity and endocrine dysfunction but is not an immediate threat to life.
• Option 3 (Consuming 400 calories/day): This is an extremely low caloric intake that confirms the eating disorder behavior and leads to malnutrition. However, the report of intake is subjective, and the immediate danger comes from the physiological consequences of that intake (like bradycardia), not the report itself.

Related Concepts: In psychiatric nursing, safety always comes first. The ABCs (Airway, Breathing, Circulation) framework applies here. The bradycardia is a direct threat to "Circulation." Other severe complications of AN include refeeding syndrome, osteoporosis, and severe electrolyte disturbances.

Concept Summary

Finding	What It Indicates	Priority Level
Key Point! Bradycardia (HR 임상 시나리오 Nursing Clinical Practice Guide Clinical Scenario: You are the nurse on an inpatient psychiatric unit. A 19-year-old female, "Emma," is admitted with a diagnosis of Anorexia Nervosa. During your initial assessment, you note she is cachectic, her skin is dry and cool, and she has lanugo hair on her face. As you take her vital signs, you find her heart rate is 45 bpm and irregular by palpation and auscultation. Nursing Intervention Strategy: Immediate Action (Assessment & Safety): Stay with the client. Attach a cardiac monitor immediately to visualize the rhythm. Check her blood pressure and oxygen saturation. Notify the charge nurse and physician/provider STAT. This client may need transfer to a medical unit or ICU for closer monitoring. Comprehensive Assessment: While awaiting orders, perform a focused assessment. Ask about dizziness, chest pain, palpitations, or syncope. Obtain orders for STAT electrolytes (K+, Mg2+, PO4-, Ca2+), an ECG, and possibly a cardiac troponin. Care Planning: The immediate nursing diagnoses are Decreased Cardiac Output and Risk for Unstable Blood Glucose Level. The plan focuses on stabilizing vital functions before addressing the eating disorder behavior. Implementation & Monitoring: Implement cardiac monitoring. Administer prescribed electrolyte replacements cautiously (often via IV). Begin nutritional rehabilitation very slowly under a strict protocol to avoid refeeding syndrome. Monitor vital signs every 15 minutes to 1 hour initially. Patient Education & Support: Once medically stable, explain the connection between nutrition and heart health in simple terms. Engage her in a therapeutic alliance. Education at this acute stage is supportive and focused on safety, not calorie counting. Patient Safety and Precautions: Contraindications: Do not force high-calorie meals initially. Do not leave the client unsupervised during meals or after if she is at risk for purging. Medication Cautions: Be extremely cautious with any medications that can prolong the QT interval (common in psychotropics). Always check an ECG before administration if bradycardia or electrolyte disturbances are present. Key Monitoring Points: Heart rate/rhythm, orthostatic blood pressure changes, daily weights (in a gown, after voiding, same scale), strict I&O (Intake & Output), and signs of refeeding syndrome (edema, confusion, heart failure). Nursing Procedure & Medication Flow For Electrolyte Replacement (e.g., Potassium Chloride IV): Dilution & Route: Must always be diluted in IV fluid. Never give IV push (bolus) – it can cause cardiac arrest. Rate Limit: Infusion rates are strictly limited (e.g., often no more than 10 mEq/hour via peripheral line unless in ICU with central line monitoring). Always use an infusion pump. Monitoring: Monitor ECG during infusion. Check serum potassium levels frequently to avoid overcorrection leading to hyperkalemia. A Word from Your Senior Nurse "Remember, patients with severe anorexia are some of the most medically fragile patients you will encounter in psychiatry. Their denial of illness is part of the disease, so they may not report symptoms. You are their lifeline. Trust your assessment skills – that slow, irregular pulse is a screaming alarm bell. In clinical practice and on the NCLEX, thinking 'What will kill my patient first?' is the cornerstone of safe, effective nursing. Mastering this prioritization will make you an invaluable nurse." 핵심 개념 Anorexia Nervosa — An eating disorder characterized by an intense fear of gaining weight, a distorted body image, and severe restriction of food intake leading to significantly low body weight. Bradycardia — A heart rate slower than the normal range (typically Refeeding Syndrome — A potentially fatal shift in fluids and electrolytes (especially phosphate, potassium, magnesium) that may occur when nutrition is restarted in a severely malnourished patient. Amenorrhea — The absence of menstrual periods for at least three cycles. In AN, it is caused by hypothalamic suppression due to low weight and fat mass. Hypokalemia — A low serum potassium level ( Practice Questions 3,332 문제 · 로그인 없이 바로 볼 수 있어요 마이메르시로 국가고시 완벽 대비 기출문제와 상세 해설을 무료로. 내 약점을 분석하고 진도를 관리하며 더 똑똑하게 공부하세요. 무료로 시작하기 App Store Google Play 학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.