# A 17-year-old is admitted with severe anorexia nervosa, BMI 15.8 kg/m2, 22% weight loss over 4 months, and recent syncope. Which actions are appropriate on the first day? Select all that apply.

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> subject: Crisis Intervention  
> category: PSI

## Question

A 17-year-old is admitted with severe anorexia nervosa, BMI 15.8 kg/m2, 22% weight loss over 4 months, and recent syncope. Which actions are appropriate on the first day? Select all that apply.

1

Begin 3,000 kcal/day immediately and postpone electrolyte testing until symptoms develop so weight restoration proceeds rapidly

2

Follow the high-risk refeeding protocol, give prescribed thiamine, start nutrition cautiously, and closely monitor phosphate, magnesium, and potassium

3

Schedule vigorous aerobic exercise during early refeeding to strengthen the myocardium and limit fat gain during medical stabilization

4

Focus therapeutic communication on feelings, behaviors, coping, and function rather than praising or criticizing appearance and weight

5

Allow unsupervised daily self-weighing and unrestricted bathroom access after meals to promote autonomy during medical stabilization

6

Provide meal and post-meal observation, including bathroom supervision, for the time specified by the eating-disorder protocol

## Explanation

Rapid carbohydrate delivery in a severely malnourished client can cause dangerous phosphate, potassium, magnesium, fluid, and thiamine shifts. Use the facility's high-risk refeeding protocol, administer thiamine, initiate ordered nutrition cautiously, and monitor electrolytes closely during the highest-risk first days (Choice 2). Meal and post-meal observation and supervised bathroom access are structured according to the program and the client's purging risk (Choice 6). Communication should address feelings, behaviors, coping, and function without reinforcing weight or appearance preoccupation (Choice 4). Starting a very high intake before risk assessment and delaying laboratory monitoring is unsafe (Choice 1). Exercise is restricted during medical instability and advanced only by the treatment team (Choice 3). Weight measurement and post-meal access are supervised according to protocol during stabilization rather than left unrestricted (Choice 5).

## In-depth explanation

Clinical Judgment
The first 7 to 10 days of an anorexia admission are dominated by refeeding-syndrome prevention, not by rapid weight restoration. Layer the care: slow calorie advance + daily electrolytes + meal/post-meal supervision + body-neutral communication + activity restriction.

Memory Tip
Refeeding labs to track = P-Mg-K (phosphate, magnesium, potassium) plus thiamine before glucose. Caloric ramp = 10–20 kcal/kg/day → advance over 7–10 days.

KR vs US
Korean adolescent eating disorder care often uses outpatient family-based therapy first, but inpatient admission is required when BMI is below 16 or vital signs are unstable. NCLEX-RN expects the nurse to apply the slow-refeeding bundle from day one and to use weight-neutral therapeutic communication.

## Clinical scenario

Clinical Practice Guide
APA, NICE, and AAP eating disorder guidelines: admit when BMI < 16, weight loss > 25 percent, syncope, bradycardia < 50, or electrolyte derangement. Begin refeeding at 10–20 kcal/kg/day, supplement thiamine before any glucose, replace phosphate, magnesium, and potassium proactively, and monitor ECG for prolonged QT. Therapy = CBT-E for adults and family-based therapy (FBT/Maudsley) for adolescents.

Caution
Common NCLEX traps: aggressive caloric advance, unsupervised weighing, comments on appearance, and exercise as a wellness reward. Remember: a hungry heart can stop — refeed slowly, watch P-Mg-K, restrict activity.

## Key concepts

- **Anorexia Nervosa** — DSM-5 eating disorder defined by restriction of energy intake leading to significantly low body weight (BMI typically below 18.5 in adults; below the 5th percentile in children), intense fear of weight gain, and disturbed body image. Subtypes: restricting and binge-eating/purging. Highest mortality of any psychiatric illness. NCLEX exam tip: severe anorexia at BMI < 16 or with cardiovascular instability requires inpatient stabilization.
- **Refeeding Syndrome** — Life-threatening fluid and electrolyte shifts that occur when malnourished clients resume nutrition. Insulin surge drives phosphate, magnesium, and potassium into cells, causing hypophosphatemia, hypomagnesemia, hypokalemia, dysrhythmias, heart failure, and Wernicke encephalopathy if thiamine is deficient. Prevention: start at 10 to 20 kcal/kg/day, replace electrolytes proactively, give thiamine before any glucose, monitor labs daily for the first week. NCLEX exam tip: aggressive day-one calorie loading is the most common wrong-answer choice.
- **Supervised Weighing Protocol** — Standardized weighing procedure to prevent manipulation in eating-disorder care: same scale, same time of day, hospital gown only, after voiding, back-to-scale (number not shown to client), and witnessed by staff. Weights are not negotiable and not shared without therapeutic context. NCLEX exam tip: any option that allows independent or self-monitored weighing in active eating-disorder care is wrong.

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