# A nurse is caring for a 22-year-old male client with anorexia nervosa who has been admitted to the psychiatric unit. The client's vital signs show: temperature 97.0°F (36.1°C), heart rate 48 bpm, blood pressure 90/55 mmHg, and respirations 14/min. The client appears cachectic with a BMI of 15.8 kg/m², reports fatigue and cold intolerance, and has laboratory results revealing hypomagnesemia and hypophosphatemia. Which nursing intervention should be the priority?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=319725  
> language: ko  
> subject: Mental Health

## 문제

A nurse is caring for a 22-year-old male client with anorexia nervosa who has been admitted to the psychiatric unit. The client's vital signs show: temperature 97.0°F (36.1°C), heart rate 48 bpm, blood pressure 90/55 mmHg, and respirations 14/min. The client appears cachectic with a BMI of 15.8 kg/m², reports fatigue and cold intolerance, and has laboratory results revealing hypomagnesemia and hypophosphatemia. Which nursing intervention should be the priority?

The client appears emaciated with a BMI of 14.2 kg/m² and reports feeling dizzy when standing. Laboratory results reveal hypokalemia and hyponatremia.

## 보기

1. Implement continuous cardiac monitoring immediately **✔ 정답**
2. Encourage the client to participate in group therapy sessions
3. Provide nutritional education about balanced meal planning
4. Establish a therapeutic relationship through active listening

**정답: 1**

## 해설

Continuous cardiac monitoring is priority due to severe bradycardia (45 bpm), hypotension, and electrolyte imbalances that can cause life-threatening arrhythmias in this high-risk anorexia patient.

## 심화 해설

Core Nursing Explanation
This question tests the critical nursing skill of prioritization in a patient with severe Anorexia Nervosa (AN). The core theme is recognizing that the most immediate threat to life is not the psychiatric disorder itself, but the severe physiological complications of starvation. The patient's data paints a picture of a body in a state of severe energy conservation and metabolic compromise.

**Key Concept Analysis**
The patient presents with multiple red flags indicating medical instability:
*   Severe Bradycardia (HR 48 bpm): In AN, the heart muscle atrophies and metabolic rate plummets. The body slows the heart to conserve energy, but this bradycardia is pathological and can progress to fatal arrhythmias like asystole.
*   Hypotension (BP 90/55 mmHg): Caused by dehydration, reduced cardiac output, and loss of vascular tone.
*   Cachexia and Low BMI (15.8 kg/m²): Indicates severe malnutrition and protein-energy wasting.
*   Electrolyte Imbalances (Hypomagnesemia, Hypophosphatemia): These are critical. Magnesium and phosphate are essential for cardiac muscle function and cellular energy production (ATP). Deficits directly increase the risk of Key Point! life-threatening cardiac arrhythmias (e.g., torsades de pointes) and are hallmarks of impending Refeeding Syndrome.

**Answer Rationale**
Key Point! The priority nursing intervention is Implement continuous cardiac monitoring immediately. This is based on the ABCs (Airway, Breathing, Circulation) of prioritization. The patient's circulation is critically compromised by bradycardia, hypotension, and electrolyte disturbances that create a perfect storm for sudden cardiac arrest. Continuous monitoring allows for immediate detection and intervention for arrhythmias, making it a life-saving action. This intervention directly addresses the greatest and most immediate risk to patient safety.

**Distractor Analysis**
*   Watch out for confusion! Option ② (Group therapy) and ④ (Therapeutic relationship) are essential psychiatric nursing interventions for AN, addressing the core psychological issues. However, according to Maslow's Hierarchy of Needs and nursing prioritization principles, physiological safety (circulation) must be secured before addressing psychosocial needs.
*   Option ③ (Nutritional education) is a crucial component of long-term recovery but is **contraindicated as an initial priority**. Initiating aggressive nutritional counseling or refeeding without first stabilizing the patient and monitoring for refeeding syndrome can be dangerous. The priority is to medically stabilize the patient so that nutritional rehabilitation can be done safely.

**Related Concepts**
This case integrates concepts from medical-surgical nursing (cardiac monitoring, electrolyte management) and psychiatric nursing. The nurse must function as an integrator, recognizing when a psychiatric patient requires acute medical intervention. Understanding Refeeding Syndrome—a potentially fatal shift of electrolytes and fluids that occurs when nutrition is restarted in a severely malnourished patient—is critical. Hypophosphatemia is its hallmark.

Concept Summary
*   **Primary Threat:** Physiological instability (cardiac arrhythmia, refeeding syndrome) over psychological symptoms.
*   **NCLEX Priority Framework:** ABCs (Airway, Breathing, Circulation) & Maslow's Physiological Needs.
*   **Key Lab Values:** Monitor K+, Mg2+, PO4- (Phosphate), Na+.
*   **Underlying Pathophysiology:** Starvation → Body conserves energy (↓HR, ↓BP, ↓Temp) → Cardiac muscle wasting & electrolyte depletion → High risk for arrhythmia/cardiac arrest.

Side-by-Side Comparison!

| Priority in Acute Medical Instability (This Case) | Priority in Stabilized Psychiatric Care |
| --- | --- |
| 1. Continuous cardiac monitoring | 1. Establish therapeutic relationship |
| 2. Monitor vital signs & electrolytes | 2. Supervised meals & nutritional support |
| 3. Implement refeeding protocol cautiously | 3. Cognitive-behavioral therapy (CBT) |
| 4. Ensure physical safety (fall risk) | 4. Address body image distortion |

Anatomy, Physiology & Pharmacology Points
*   **Cardiac Physiology:** The heart requires magnesium for proper electrical conduction and phosphate for ATP production. Deficiencies lead to prolonged QT interval and weak cardiac contractions.
*   **Endocrine Physiology:** Starvation lowers thyroid hormone (T3), contributing to bradycardia, hypotension, and cold intolerance.
*   **Pharmacology:** Electrolyte replacements (IV Magnesium sulfate, Potassium phosphate) may be administered, but slowly and with close monitoring to avoid overload.

Memory Tips
*   **Acronym "HEART":** In Anorexia, monitor **H**eart rate (Bradycardia), **E**lectrolytes, **A**rrhythmia risk, **R**efeed carefully, **T**emperature (Hypothermia).
*   **Rule of Thumb:** If the patient with an eating disorder has a heart rate < 50 bpm, systolic BP < 90 mmHg, or critical electrolyte imbalances, think "MEDICAL EMERGENCY, not just therapy."

High-Frequency NCLEX Topics
This is a classic NCLEX "priority" or "first" question. The exam loves to test your ability to distinguish between a psychosocial need and a physiological emergency in psychiatric patients. Always assess physiological stability (ABCs, vital signs, labs) first.

Watch Out for Question Variations!
*   **Shift from Symptom to Intervention:** "The nurse notes the client's heart rate is 44 bpm. Which action should the nurse take *first*?" (Answer: Assess blood pressure and attach cardiac monitor).
*   **Shift to Refeeding Syndrome:** "The client with anorexia has started nutritional supplements. Which finding requires immediate intervention?" (Answer: Serum phosphate level of 1.5 mg/dL).
*   **Shift to Discharge Planning:** "Which outcome indicates the client is ready for outpatient treatment?" (Answer: Vital signs and electrolyte levels have been stable within normal range for one week).

## 임상 시나리오

Nursing Clinical Practice Guide
**Clinical Scenario:** You are the nurse on a psychiatric unit admitting "Alex," a 22-year-old with severe anorexia nervosa. He is frail, wrapped in multiple layers, and his heart rate on the monitor reads 48. His lab results just came back showing critically low magnesium and phosphate.

**Nursing Intervention Strategy**
1.  **Immediate Assessment & Safety:** Place Alex on continuous cardiac monitoring **immediately** upon admission. Obtain a full set of vital signs, including orthostatic blood pressures (he reports dizziness). Perform a focused cardiac and respiratory assessment.
2.  **Monitoring & Collaboration:** Notify the physician/psychiatrist and likely request a medical consult. Strictly monitor intake and output (I&O). Weigh daily at the same time, in a hospital gown, after voiding.
3.  **Nutritional Rehabilitation - CAUTIOUSLY:** Collaborate with the dietitian. Initiate refeeding slowly, often starting with as little as 1200-1500 kcal/day, with frequent small meals. **Never** allow unlimited access to food or fluids initially.
4.  **Psychosocial Support:** Once medically stable, engage Alex. Use a non-judgmental approach. Sit with him during meals for support (not coercion). Gradually introduce group therapy focusing on body image and coping skills.

**Patient Safety and Precautions**
*   **Refeeding Syndrome:** The first 3-5 days of refeeding are the highest risk. Monitor for edema, heart failure signs, and **serum phosphate, magnesium, and potassium levels daily**.
*   **Cardiac Arrest Risk:** Have emergency equipment (crash cart) accessible. Bradycardia can rapidly deteriorate.
*   **Fall Risk:** Muscle weakness, orthostatic hypotension, and dizziness make falls a major concern. Implement fall precautions.

Nursing Procedure & Medication Flow
*   **Cardiac Monitoring:** Ensure proper lead placement. Set alarm parameters appropriately (e.g., low HR alarm at 50 bpm initially). Document rhythm strips per protocol.
*   **Electrolyte Replacement:** If administering IV magnesium or phosphate:
*   Infuse **slowly** as per protocol (e.g., magnesium sulfate often over 1-4 hours).
*   Monitor for toxicity: loss of deep tendon reflexes (Mg), diarrhea (PO4), and cardiac changes.
*   Always use an IV pump for controlled infusion.
*   **Vital Sign Protocol:** Monitor vital signs every 4 hours or more frequently as ordered. Always assess for orthostatic changes before allowing the patient to ambulate.

A Word from Your Senior Nurse
Caring for a patient with severe anorexia is one of the most humbling experiences. You are balancing the role of a **medical nurse** guarding their fragile body and a **psychiatric nurse** connecting with their tortured mind. Remember, you cannot therapy away a cardiac arrest. Your first job is to keep them alive. That vital sign monitor isn't just a machine; it's your early warning system. When you see that slow, steady bradycardia, understand it's a heart whispering, "I'm barely hanging on." Your vigilant monitoring and swift action give that heart the chance to recover so the real healing—the mental healing—can begin. On the NCLEX and in practice, never forget: safety first, always.

## 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 reintroduced to a severely malnourished patient.
- **Hypophosphatemia** — Low serum phosphate level (
- **Cachexia** — A state of profound malnutrition, weight loss, and muscle wasting, often seen in chronic diseases like cancer or severe anorexia nervosa.

## 같은 주제 문제

- [A nurse is caring for a client with bulimia nervosa who has been admitted to the medical u…](https://mymerci.kr/pages/nclex_q.php?qn_id=319726)
- [A nurse is caring for an 18-year-old female client with anorexia nervosa who has been admi…](https://mymerci.kr/pages/nclex_q.php?qn_id=319727)
- [A nurse is caring for a client with anorexia nervosa who has been admitted to the medical …](https://mymerci.kr/pages/nclex_q.php?qn_id=319728)
- [A nurse is caring for a client with bulimia nervosa in an outpatient clinic. The client re…](https://mymerci.kr/pages/nclex_q.php?qn_id=319729)
- [A nurse is caring for a client with bulimia nervosa who has been admitted to the psychiatr…](https://mymerci.kr/pages/nclex_q.php?qn_id=319730)
- [A nurse is caring for a client with bulimia nervosa who has been admitted to the psychiatr…](https://mymerci.kr/pages/nclex_q.php?qn_id=319731)
- [A nurse is assessing a 19-year-old female client admitted to the psychiatric unit with sus…](https://mymerci.kr/pages/nclex_q.php?qn_id=319732)
- [A nurse is assessing a 19-year-old female client admitted with suspected anorexia nervosa.…](https://mymerci.kr/pages/nclex_q.php?qn_id=319733)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._