# A 28-year-old woman is admitted to the inpatient psychiatric unit with a 3-year history of anorexia nervosa, current BMI 16.2, and self-reported daily diuretic misuse. Today serum potassium is 2.9 mEq/L. She also has major depression. The admitting prescriber has just ordered bupropion XL 300 mg PO daily. Which action should the nurse take?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375259&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A 28-year-old woman is admitted to the inpatient psychiatric unit with a 3-year history of anorexia nervosa, current BMI 16.2, and self-reported daily diuretic misuse. Today serum potassium is 2.9 mEq/L. She also has major depression. The admitting prescriber has just ordered bupropion XL 300 mg PO daily. Which action should the nurse take?

## Option

1. Hold the order, notify the prescriber about the active eating disorder, low BMI, diuretic misuse, and hypokalemia, and request an alternative antidepressant. **✔ Correct answer**
2. Administer the bupropion XL as ordered, document the patient's eating disorder and hypokalemia, and monitor for signs of seizure activity during the shift.
3. Hold the bupropion order and administer fluoxetine 20 mg orally, explaining that it is approved for bulimia and safer for patients with eating disorders.
4. Administer the bupropion as ordered but hold the patient's diuretic and recheck potassium in the morning before giving the next dose.

**Correct answer: 1**

## Explanation

Bupropion carries a boxed and labeled contraindication in patients with current or prior anorexia nervosa or bulimia, because these patients have a markedly higher seizure rate on bupropion (~1 in 1000 in general use, several-fold higher with eating disorders, electrolyte derangement, or seizure history). Hypokalemia from diuretic misuse further lowers the seizure threshold. The nurse must hold the order, alert the prescriber, and request an alternative antidepressant (SSRI such as fluoxetine, which has the only FDA approval in bulimia, or another non-bupropion option). Bupropion does not improve appetite — it tends to suppress it and cause weight loss, worsening the eating disorder. Skipping meals or simply documenting and giving an unsafe drug are both unsafe nursing actions.

## In-depth explanation

Three layered red flags: anorexia/bulimia (boxed), low BMI/electrolyte loss (lowers threshold), and diuretic-induced hypokalemia (lowers threshold). Any one would justify holding bupropion; all three together require immediate prescriber contact.

## Clinical scenario

Scenario 28-year-old woman admitted to inpatient psychiatry. Diagnosis: anorexia nervosa restricting type with diuretic misuse, MDD. BMI 16.2, weight 42 kg, height 161 cm. Vitals: HR 52, BP 92/58, T 36.1°C, RR 14. Labs: K 2.9 mEq/L, Mg 1.5 mg/dL, Na 134, bicarbonate 30, EKG with prolonged QTc 470 ms. New order: bupropion XL 300 mg PO daily. No prior seizure history but multiple known seizure risk factors are present.

## Key concepts

- **Bupropion contraindications** — Active or prior anorexia nervosa or bulimia, current or prior seizure disorder, abrupt cessation of alcohol, benzodiazepines, or barbiturates, and concurrent MAOI within 14 days. Mechanism: NDRI lowers seizure threshold dose-dependently.
- **Eating disorder pharmacology** — Fluoxetine 60 mg/day is the only FDA-approved medication for bulimia nervosa; no medication is FDA-approved as core treatment of anorexia nervosa, where weight restoration and psychotherapy are primary. Bupropion is contraindicated in both.
- **Refeeding-related risks** — Severely malnourished patients also risk refeeding syndrome (low phosphate, magnesium, potassium, thiamine deficiency, fluid overload, arrhythmias). Cardiac monitoring, slow caloric advancement, and electrolyte/thiamine repletion are required regardless of antidepressant choice.

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