— 心理社會完整性 · HARD · MCQ —
一位厭食症病人入院。下列哪個評估結果需要最立即的護理處置？
A client with anorexia nervosa is hospitalized. Which assessment finding requires the most immediate nursing action?
- APreoccupation with food and calories對食物和熱量執著
- BHeart rate of 42 beats per minute✓ 正解心率每分鐘42次
- CDry, scaly skin皮膚乾燥脫屑
- DLanugo growth on the back背部生長毳毛
— Explanation · 中文詳解 —
厭食症（Anorexia nervosa）病人的生理風險極高。心搏過緩（Bradycardia，如 42 bpm）是心血管系統因長期營養不良失代償的警訊，預示著心律不整甚至心臟驟停的風險。這屬於醫療危急狀態，護理師必須立即啟動監測並通知醫療團隊。其他症狀（皮膚乾燥、細毛、對食物執著）雖為厭食症典型特徵，但心搏過緩直接威脅生命。
Severe bradycardia, such as a heart rate of 42 beats per minute, indicates cardiovascular decompensation due to malnutrition and poses an immediate risk of cardiac arrest. While other symptoms like dry skin or lanugo are characteristic of anorexia nervosa, they are not life-threatening emergencies. Therefore, the nurse must prioritize addressing the hemodynamic instability by notifying the healthcare provider immediately.