# A nurse is caring for a client with anorexia nervosa who has been admitted to the medical unit with severe electrolyte imbalances. The client's vital signs show bradycardia (HR 45 bpm), hypotension (BP 85/50 mmHg), and hypothermia (T 96.2°F). The client appears emaciated with a BMI of 14.5 kg/m² and exhibits signs of severe malnutrition including lanugo, brittle nails, and dry skin. Which nursing intervention should be the highest priority?

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> subject: Mental Health

## 문제

A nurse is caring for a client with anorexia nervosa who has been admitted to the medical unit with severe electrolyte imbalances. The client's vital signs show bradycardia (HR 45 bpm), hypotension (BP 85/50 mmHg), and hypothermia (T 96.2°F). The client appears emaciated with a BMI of 14.5 kg/m² and exhibits signs of severe malnutrition including lanugo, brittle nails, and dry skin. Which nursing intervention should be the highest priority?

## 보기

1. Encourage the client to participate in group therapy sessions to address underlying psychological issues
2. Implement a structured meal plan with gradual caloric increases to restore nutritional status
3. Provide emotional support and establish a therapeutic relationship with the client
4. Initiate continuous cardiac monitoring and frequent vital sign assessment **✔ 정답**

**정답: 4**

## 해설

Continuous cardiac monitoring and frequent vital sign assessment are the highest priority due to life-threatening physiological complications like bradycardia and hypotension. This addresses immediate safety needs over psychological or nutritional interventions.

## 심화 해설

Core Nursing Explanation
**Key Concept Analysis**: This question assesses the ability to prioritize nursing interventions for a patient with severe Anorexia Nervosa (AN) experiencing life-threatening physiological instability. The core principle is Maslow's Hierarchy of Needs and the ABC (Airway, Breathing, Circulation) priority framework. The patient's data (bradycardia, hypotension, hypothermia, severe malnutrition) indicate a high risk for Refeeding Syndrome and cardiovascular collapse, which are immediate threats to survival.

**Answer Rationale**: Key Point! The highest priority is Initiate continuous cardiac monitoring and frequent vital sign assessment. The patient's vital signs are critically abnormal: HR 45 bpm (severe bradycardia), BP 85/50 mmHg (hypotension), and T 96.2°F (35.7°C) (hypothermia). These are signs of severe physiological compromise from starvation, affecting the heart muscle and autonomic nervous system. Continuous monitoring is essential to detect life-threatening arrhythmias (e.g., asystole) and guide immediate interventions like IV fluids or electrolyte replacement. This directly addresses the Circulation component of ABCs.

**Distractor Analysis**:

Watch out for confusion! Option ②, implementing a meal plan, is a **critical but not the first** priority. In a severely malnourished patient, aggressive nutritional rehabilitation *without* close physiological monitoring can trigger Refeeding Syndrome, a potentially fatal shift of electrolytes (especially phosphorus, potassium, magnesium) and fluids that can cause cardiac failure and arrhythmias. The meal plan must be initiated *after* or *concurrently with* stabilization and monitoring.

Option ①, group therapy, addresses important psychological issues but is a lower priority when the patient's physiological survival is at immediate risk (Maslow's physiological needs come before psychological needs).

Option ③, providing emotional support, is a fundamental part of therapeutic communication and building trust, which is vital for long-term recovery. However, it does not address the acute, life-threatening physical instability presented in the scenario.

**Related Concepts**: The nursing process requires constant re-prioritization. Once the patient is physiologically stable (vital signs normalized, electrolytes repleted), the priority shifts to the structured nutritional plan (option ②) and then to the psychological interventions (options ① and ③). Understanding the pathophysiology of starvation (metabolic slowdown, muscle wasting including cardiac muscle, electrolyte depletion) is key to justifying this prioritization.

Concept Summary

| Concept | Description | Application in This Case |
| --- | --- | --- |
| Anorexia Nervosa (AN) | An eating disorder characterized by restrictive eating, intense fear of weight gain, and distorted body image. | Underlying cause of the severe malnutrition and physiological complications. |
| Refeeding Syndrome | A life-threatening shift in fluids and electrolytes (hypophosphatemia, hypokalemia, hypomagnesemia) that can occur when nutrition is restarted in a severely malnourished patient. | The major risk when initiating nutritional support. Requires close monitoring of labs and cardiac status. |
| Maslow's Hierarchy | A theory prioritizing human needs: Physiological > Safety > Love/Belonging > Esteem > Self-actualization. | Justifies prioritizing cardiac monitoring (Physiological/Safety) over psychological therapy (Esteem/Belonging). |
| ABC Priority | Airway, Breathing, Circulation. The foundational framework for emergency and acute care prioritization. | The bradycardia and hypotension are direct threats to Circulation, making them the top priority. |

Side-by-Side Comparison!

| Intervention | Priority Level in Acute/Unstable Phase | Priority Level in Stable/Recovery Phase | Rationale |
| --- | --- | --- | --- |
| Cardiac Monitoring | HIGHEST (Immediate) | Low (May be discontinued) | Prevents death from arrhythmia/cardiac arrest. |
| Structured Meal Plan | High (But must be gradual & monitored) | HIGHEST (Primary treatment) | Addresses root cause but risks refeeding syndrome if done hastily. |
| Psychological Therapy | Low | HIGH (Essential for relapse prevention) | Addresses underlying disorder but requires a stable physiological base. |

Anatomy, Physiology & Pharmacology Points
**Pathophysiology:** Severe starvation leads to catabolism (breakdown) of body tissues. The heart muscle (myocardium) atrophies, leading to decreased cardiac output, bradycardia, and hypotension. The body slows its metabolic rate (hypothermia) to conserve energy. Electrolyte imbalances (from vomiting, laxative abuse, or simply depletion) further disrupt cardiac conduction.

**Monitoring Parameters:** Key labs to monitor include Phosphorus (2.5-4.5 mg/dL), Potassium (3.5-5.0 mEq/L), Magnesium (1.7-2.2 mg/dL). Low levels (Hypophosphatemia, Hypokalemia, Hypomagnesemia) are hallmarks of refeeding syndrome.

Memory Tips
**Acronym: "MONITOR First"**

**M**onitor (Cardiac/Vitals)

**O**vercome (Electrolyte imbalances)

**N**ourish (Gradually with a meal plan)

**I**nvestigate (Psychological triggers)

**T**herapy (Group/Individual)

**O**utpatient (Plan for follow-up)

**R**elapse prevention

**Mnemonic for Refeeding Syndrome Risks:** "**P**lease **K**eep **M**y **H**eart **B**eating" - Phosphorus, Potassium, Magnesium, Heart monitoring, Bradycardia.

High-Frequency NCLEX Topics
The NCLEX-RN frequently tests priority-setting and delegation in unstable patients. Anorexia Nervosa scenarios often combine psychiatric nursing with medical-surgical acute care. You must be able to identify when a psychological condition has created a physiological emergency and act accordingly. Remember: "Safety and Survival First."

Watch Out for Question Variations!
*   Instead of asking for the priority intervention, the question might ask: "**Which finding requires immediate intervention?**" The answer would still be the bradycardia/hypotension.
*   The question could shift to the **stable phase**: "The client's vital signs have normalized. Which intervention is now the priority?" The answer would likely be the structured meal plan (option ②).
*   It could test **knowledge of refeeding syndrome**: "When initiating the meal plan, the nurse should monitor for which electrolyte imbalance?" Answer: Hypophosphatemia.

## 임상 시나리오

Nursing Clinical Practice Guide
**Clinical Scenario:** You are the nurse on a medical unit admitting "Jordan," a 19-year-old with a known history of Anorexia Nervosa, brought in by family due to extreme weakness and fainting. Jordan is cachectic, withdrawn, and has the vital signs listed. Your initial assessment confirms the presence of lanugo (fine body hair), peripheral edema (a sign of possible refeeding syndrome or protein deficiency), and cool, dry skin.

**Nursing Intervention Strategy:**
1.  **Immediate Assessment & Monitoring (Priority):** Place Jordan on a cardiac monitor immediately upon arrival. Establish IV access with a saline lock. Obtain a full set of vital signs (including orthostatic BP and pulse) every 15-30 minutes initially. Attach pulse oximetry. Perform a focused cardiovascular and respiratory assessment.
2.  **Collaboration & Diagnostics:** Notify the physician/provider STAT about the bradycardia and hypotension. Anticipate orders for STAT electrolytes (CMP, Mg, Phos), ECG, and possibly a chemistry panel. Prepare for possible transfer to a higher level of care (e.g., step-down unit) if instability persists.
3.  **Safe Nutritional Initiation:** Once stable, collaborate with the dietitian and treatment team. The initial meal plan will be very low calorie (e.g., 1200 kcal/day), divided into 6 small meals/snacks to reduce gastric distress and metabolic shock. **Never** allow the patient unlimited access to food or water initially.
4.  **Therapeutic Communication & Safety:** Use a calm, non-judgmental approach. Set clear, consistent limits. Meals are non-negotiable but supervised in a supportive manner. Monitor for covert behaviors like hiding food, exercising in secret, or water-loading before weight checks.

**Patient Safety and Precautions:**
*   **Contraindications:** Do not force rapid high-calorie intake. Avoid using food as a reward/punishment.
*   **Medication Cautions:** Be extremely cautious with any medications that can further lower heart rate (e.g., beta-blockers) or prolong the QT interval. Many psychotropic medications require careful titration in malnourished patients.
*   **Key Monitoring Points:** Daily weights (in a hospital gown, after voiding, same scale), strict I&O, frequent electrolyte checks (especially first 5-7 days of refeeding), and continuous observation for signs of fluid overload (edema, crackles) or cardiac arrhythmia.

Nursing Procedure & Medication Flow
**Procedure: Managing the High-Risk AN Patient**
1.  **Admission:** Complete a thorough physical and psychosocial assessment. Establish baseline.
2.  **Stabilization:** Implement cardiac monitoring, IV access, frequent VS. Administer electrolyte replacements (IV or PO) as ordered.
3.  **Refeeding:** Initiate prescribed diet. Supervise all meals and for 1 hour post-meal (to prevent purging). Provide prescribed nutritional supplements.
4.  **Evaluation:** Monitor trends in VS, weight, labs, and behavioral compliance. Adjust care plan accordingly.

**Medication Example - Potassium Chloride (KCl) Replacement:** If hypokalemic, KCl may be ordered. **Precautions:** Never give IV push. For IV infusion, concentration and rate are critical (e.g., usually no more than 10 mEq/hr via peripheral line). Monitor for phlebitis. Always check renal function before administering.

A Word from Your Senior Nurse
Caring for patients with severe anorexia is one of the most challenging and delicate balances in nursing. You are simultaneously a physiological lifeguard and a compassionate coach. That initial instinct to "just feed them" must be tempered with expert knowledge of the deadly risks. Your vigilant monitoring of a slow heart rate or a dropping phosphate level isn't just a task—it's what stands between your patient and cardiac arrest. On the NCLEX and in practice, this principle is universal: **you cannot treat the mind if the body is crashing.** Master the "why" behind the priority, and you'll make safe, confident decisions every time.

## 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.
- **Refeeding Syndrome** — A potentially fatal shift in fluids and electrolytes (especially phosphorus, potassium, magnesium) that may occur when nutritional support is started in a severely malnourished patient, leading to cardiac, respiratory, and neurological complications.
- **Bradycardia** — A heart rate slower than the normal range (typically
- **Maslow's Hierarchy of Needs** — A psychological theory prioritizing human needs in a pyramid: physiological needs (food, water, warmth) form the base, followed by safety, love/belonging, esteem, and self-actualization at the top. Used in nursing to prioritize care.
- **Hypophosphatemia** — A low serum phosphate level (

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