A client with a diagnosis of anorexia nervosa has a body mass index (BMI) of 15 and is exhibiting bradycardia and hypotension. The client refuses to eat, stating, 'I'm fat and ugly.' Which nursing intervention is the most appropriate initial action?
- AMonitor vital signs frequently and ensure a safe, structured environment for refeeding.
- BConfront the client's distorted body image by showing them their BMI chart.
- CNegotiate a contract with the client for specific food intake goals.
- DAdminister prescribed supplemental feedings via nasogastric tube.
Show answer & explanationAnswer & explanation
Correct answer: A. Monitor vital signs frequently and ensure a safe, structured environment for refeeding.
With a BMI of 15 and vital sign instability (bradycardia, hypotension), the client is at high risk for refeeding syndrome and cardiac complications. The immediate priority is continuous physiological monitoring and establishing a safe, structured environment for refeeding, which often begins slowly under strict medical supervision to prevent life-threatening electrolyte shifts. This addresses the most immediate physiological threat.
Why the other options are wrong
- B. Confronting distorted body image is not an initial priority and can be counterproductive, increasing resistance and anxiety.
- C. Negotiating food intake is part of treatment, but the immediate priority is physiological stabilization and safe refeeding, which may involve medical intervention rather than negotiation.
- D. While supplemental feedings may be necessary, it's a medical order. The nurse's immediate action is to prepare for and safely manage the refeeding process, starting with monitoring.
Anorexia Nervosa: Refeeding Syndrome Prevention
For clients with severe anorexia nervosa, the immediate priority is careful physiological monitoring and a structured refeeding process to prevent refeeding syndrome, a potentially fatal shift in fluids and electrolytes.
- Bradycardia, hypotension indicate severity.
- Refeeding syndrome risk is high.
- Slow, monitored refeeding is crucial.
Memory trick: Refeed Right, Keep Life Bright.