# A nurse is assessing a 19-year-old female client admitted with suspected anorexia nervosa. Which assessment finding would be most indicative of the severity of the client's condition and require immediate nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=319733 > language: ko > subject: Mental Health ## 문제 A nurse is assessing a 19-year-old female client admitted with suspected anorexia nervosa. Which assessment finding would be most indicative of the severity of the client's condition and require immediate nursing intervention? ## 보기 1. Orthostatic hypotension with a blood pressure drop from 110/70 mmHg sitting to 85/50 mmHg standing **✔ 정답** 2. Body mass index (BMI) of 16.5 kg/m² with a 25% weight loss from baseline 3. Amenorrhea for the past 8 months with dry, brittle hair and lanugo 4. Preoccupation with calorie counting and ritualistic eating behaviors **정답: 1** ## 해설 Orthostatic hypotension indicates severe cardiovascular compromise and dehydration, requiring immediate intervention to prevent cardiovascular collapse. Other findings like low BMI, amenorrhea, and preoccupation with food are concerning but not immediate life-threatening. ## 심화 해설 Core Nursing Explanation **Key Concept Analysis**: This question assesses the nurse's ability to prioritize life-threatening complications in a patient with Anorexia Nervosa (AN). While all findings are significant in AN, the core principle is ABC (Airway, Breathing, Circulation) priority. The question asks for the finding most indicative of severity and requiring **immediate** intervention, which points to acute physiological instability, particularly cardiovascular compromise. **Answer Rationale**: Key Point! Orthostatic hypotension is a direct sign of severe volume depletion and cardiovascular instability. A drop in systolic BP of ≥20 mmHg or diastolic BP of ≥10 mmHg upon standing is clinically significant. The drop from 110/70 mmHg to 85/50 mmHg is profound and indicates the body cannot maintain adequate perfusion. This can lead to syncope, falls, and is a precursor to cardiovascular collapse, requiring immediate interventions like fluid resuscitation and close monitoring. **Distractor Analysis**: - **Option ② (BMI of 16.5 & 25% weight loss):** This is a *diagnostic criterion* and indicates severity of the eating disorder, but it is a **chronic** finding. While critically important for long-term management, it does not signal an *immediate* threat to life in the same way acute cardiovascular instability does. - **Option ③ (Amenorrhea, brittle hair, lanugo):** These are classic signs of the body's adaptation to starvation and severe malnutrition. Amenorrhea (loss of menstrual cycle) and Lanugo (fine body hair) reflect endocrine and metabolic disturbances. They are serious but represent longer-term complications, not an acute emergency. - **Option ④ (Preoccupation & rituals):** These are the core **psychiatric symptoms** of anorexia nervosa. They are the root cause of the illness and the focus of long-term psychotherapy. However, they are not a direct physiological threat requiring immediate medical intervention. **Related Concepts**: In eating disorder nursing, the priority is always medical stabilization before psychiatric treatment. Other immediate red flags include severe electrolyte imbalances (especially hypokalemia, which can cause fatal arrhythmias), bradycardia (heart rate ## 임상 시나리오 Nursing Clinical Practice Guide **Clinical Scenario:** You are the nurse admitting "Emma," a 19-year-old college student brought to the ED by her roommate. She is extremely thin, weak, and dizzy. During your initial assessment, you take her blood pressure sitting and then standing. **Nursing Intervention Strategy:** - **Immediate Assessment & Safety:** - Upon finding orthostatic hypotension, **immediately assist the client to sit or lie down** to prevent a fall and injury. - Perform a full set of vital signs, including apical heart rate for a full minute (bradycardia is common). - Attach cardiac monitor to assess for arrhythmias or prolonged QT interval. - **Communication & Collaboration:** - Notify the physician/provider **immediately** with your findings: "Client has symptomatic orthostatic hypotension with a 25 mmHg drop in systolic BP." - Anticipate orders for STAT electrolytes (CMP, Mg, Phos), ECG, and IV access. - **Implementation of Medical Orders:** - Initiate IV fluid resuscitation as ordered (often 0.9% Normal Saline), using an **infusion pump** to control the rate carefully. - Administer electrolyte replacements (IV Potassium, Phosphate) as ordered, following strict protocols for infusion rate and concentration to avoid cardiac complications. - **Ongoing Monitoring & Supportive Care:** - Monitor intake and output (I&O) strictly. Weigh daily at the same time, in a hospital gown, after voiding. - Initiate refeeding under a strict protocol to prevent Refeeding Syndrome (monitor for fluid shifts, edema, and electrolyte crashes). - Provide a warm, non-judgmental environment. Mealtimes will be highly anxiety-provoking; your calm, consistent presence is crucial. **Patient Safety and Precautions:** - **Refeeding Syndrome:** The greatest danger in early treatment. Rapid nutritional replenishment can cause fatal shifts in fluids and electrolytes (especially phosphate, potassium, magnesium). Start nutrition slowly and monitor labs closely. - **Cardiac Monitoring:** Essential due to risks of bradycardia, arrhythmias from electrolyte imbalances, and prolonged QT interval. - **Fall Prevention:** Due to dizziness and weakness, implement fall precautions (call light within reach, non-slip socks, assist with ambulation). - **Contraindications:** Do not force feed or engage in power struggles over food. The therapeutic relationship is key. All interventions should be part of a structured, multidisciplinary plan. Nursing Procedure & Medication Flow **Managing Orthostatic Hypotension & Initiating Ref feeding:** - **Assessment:** Check BP and HR lying, sitting, standing (if tolerated). Note symptoms (dizziness, blurred vision). - **Action:** If symptomatic, keep patient supine. Establish IV access with a large-bore catheter if rapid fluid resuscitation is needed. - **Medication/IV Fluids:** - **IV Fluids:** 0.9% NaCl is typical. Rate is ordered based on degree of dehydration (e.g., 500 mL bolus, then 75-100 mL/hr). Use a pump. - **Electrolytes:** IV Potassium Chloride. **Never give IV push.** Must be diluted and infused via pump, usually no faster than 10 mEq/hr through a peripheral line (check hospital policy). Monitor ECG during infusion. - **Monitoring:** Re-check orthostatic vitals after fluid bolus. Monitor for signs of fluid overload (crackles in lungs, edema) as the malnourished heart may be weak. A Word from Your Senior Nurse Caring for a patient with severe anorexia is one of the most challenging and delicate situations in nursing. You are balancing the role of a **lifesaver** (managing their crashing physiology) with that of a **therapeutic ally** (building trust to treat their profound psychological pain). In the acute phase, your sharp assessment skills are what stand between the patient and cardiac arrest. Spotting that orthostatic hypotension isn't just a check-box—it's a critical clue that their body is running on empty. On the NCLEX and in practice, never lose sight of the ABCs. The mind cannot heal if the body is failing. Your knowledge and calm intervention in these first moments set the stage for their entire recovery journey. ## 핵심 개념 - **Orthostatic Hypotension** — A significant drop in blood pressure (typically ≥20 mmHg systolic or ≥10 mmHg diastolic) upon standing from a sitting or lying position. It indicates volume depletion or autonomic dysfunction and is a sign of acute cardiovascular instability. - **Anorexia Nervosa** — An eating disorder characterized by an intense fear of gaining weight, a distorted body image, severe restriction of food intake leading to significantly low body weight, and often an absence of menstrual periods (amenorrhea). - **Refeeding Syndrome** — A potentially fatal shift in fluids and electrolytes (especially phosphate, potassium, magnesium) that may occur when nutrition is reintroduced too rapidly to a severely malnourished patient. It can cause cardiac, respiratory, and neurological failure. - **Lanugo** — Fine, soft, downy hair that grows on the body (face, arms, back) as a physiological response to severe malnutrition and loss of body fat, serving as insulation. Common in advanced anorexia nervosa. - **Amenorrhea** — The absence of menstrual periods for at least three consecutive cycles. In anorexia nervosa, it is caused by the suppression of the hypothalamic-pituitary-gonadal axis due to severe weight loss and low body fat. ## 같은 주제 문제 - [A nurse is caring for a 22-year-old male client with anorexia nervosa who has been admitte…](https://mymerci.kr/pages/nclex_q.php?qn_id=319725) - [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. 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