Rationale: Squamous cell carcinoma of the esophagus is the seventh leading cause of cancer death among men, particularly black men; mean age at diagnosis is 67 years. Alcohol and tobacco use are the main risk factors for this cancer, and dysphagia is a common presenting complaint. An esophageal motility disorder involves the smooth muscle layer of the esophagus and the lower esophageal sphincter (LES). Achalasia is characterized by difficulty swallowing and regurgitation. GERD (gastroesophageal reflux disease) is a condition that causes the esophagus to become irritated and inflamed. Clients with GERD usually feel a burning in the chest or throat called heartburn. Sometimes, they taste stomach fluid in the back of the mouth.

Rationale: The nurse should consider which conditions are treated with ulcerogenic medications. In this group of clients, the client with atrial fibrillation and ischemic heart disease is most at risk. Clients with atrial fibrillation are usually prescribed anticoagulants for stroke prevention, and aspirin (an ulcerogenic non-selective NSAID) would be prescribed for prevention of myocardial infarction related to coronary artery disease. The client at next greatest risk for gastrointestinal bleeding would be the client with rheumatoid arthritis, as these clients are often treated with myelosuppressive medications that can lower platelet counts, and/or corticosteroids which are ulcerogenic. The client with diabetes and the elderly client would be considered lower risk than the first two based on the treatments for their conditions.

Rationale: People with dysphagia usually complain of choking, coughing, or an abnormal sensation of food sticking in the back of the throat or upper chest when they swallow. A neuromuscular cause involves lesions of the CNS, such as a stroke, which often involve the cranial nerves that control swallowing. Feeding in upright position is good once it is determined by swallowing evaluation that the client can swallow food without it going into the lungs. Likewise, thickening agents help clients with dysphagia after a swallow evaluation has been performed. No action could put the client at risk for aspiration pneumonia.

Rationale: Esophagitis secondary to reflux can cause feeding problems, early satiety, and hematemesis. Infants may demonstrate signs of pain when swallowing and may be irritable and cry frequently. Rotavirus causes diarrhea and vomiting, but not the other symptoms. Appendicitis is inflammation of the appendix. Appendicitis usually starts with the main symptom of pain around the navel that moves to the lower right abdomen. Hirschsprung disease is a blockage of the large intestine due to improper muscle movement in the bowel. It is a congenital condition, which means it is present from birth. In Hirschsprung disease, the nerves are missing from a part of the bowel. One primary sign/symptom is a failure to pass meconium shortly after birth.

Rationale: Vomiting or emesis is the sudden and forceful oral expulsion of the contents of the stomach. It is usually preceded by nausea. Nausea is a subjective and unpleasant sensation. Retching consists of rhythmic spasmodic movements of the diaphragm, chest wall, and abdominal muscles. It usually precedes or alternates with periods of vomiting. Expatriate means to banish or withdraw.

Rationale: Inflammatory diarrhea is often characterized by small-volume diarrhea that is bloody and accompanied by a fever. Non-inflammatory diarrhea is normally larger in volume and not bloody. Factitious diarrhea is normally attributable to laxative use and secretory diarrhea is associated with increased secretory processes of the bowel; neither is likely to produce bloody stool.

Rationale: Family history, NSAID use, and smoking have all been identified as contributing factors in the development of peptic ulcers. Diet therapy has not been shown to be effective and duodenal peptic ulcers are more common than the gastric variant. Perforation occurs when an ulcer erodes through all layers of the stomach or duodenum wall. When perforation occurs in older adults, their mortality is significantly increased. Effective medication regimens are available with antacids, histamine-2 (H ₂) receptor antagonists or proton pump inhibitors being the most common medications used.

Rationale: The act of swallowing depends on the coordinated action of the tongue and pharynx. These structures are innervated by cranial nerves V (trigeminal), IX (glossopharyngeal), X (vagus), and XII (hypoglossal). Cranial nerve I is olfactory and CN XI is accessory, neither of which is involved in swallowing.

Rationale: Replacement of fluids and electrolytes is considered to be a primary therapeutic goal in the treatment of diarrhea. Water absorption from the intestines is linked to osmotically active particles such as glucose and sodium. It follows that an important consideration in facilitating the transport of water across the intestine (and decreasing diarrhea) after temporary disruption in bowel function is to include sodium and glucose in the fluids that are consumed.

Rationale: The etiology of cancer of the colon and rectum remains largely unidentified, though dietary factors are thought to exist. The prognosis, especially with stage III tumors, is poor. Simple and accurate screening tests do exist for colorectal cancer, while drugs are not implicated in the etiology.

Rationale: The client is exhibiting symptoms of pseudomembranous colitis, which is characterized by an adherent inflammatory membrane overlying the areas of mucosal injury. A history of C. difficile combined with acute symptoms such as lethargy, fever, tachycardia, abdominal pain and distention should alert the nurse that the client may be experiencing this life-threatening condition; the health care provider should notified immediately as prompt therapy is needed to prevent perforation of the bowel. The nurse should not ignore these warning signs and administer the ordered medications as this would delay treatment.

Rationale: Acute gastritis associated with alcohol use is characterized by intermittent vomiting and the possibility of hematemesis. Aspirin and H. pylori do not normally cause such an acute symptom onset and infectious organisms do not normally cause bleeding of the stomach lining. A combination of calcium carbonate and magnesium is commonly found in antacids. Overdose of antacids can result in irregular heartbeat; poor balance; shallow and rapid breathing; and stupor (lack of alertness).

Rationale: People at high risk for development of stress ulcers include those with large surface area burns, trauma, sepsis, acute respiratory distress syndrome, severe liver failure, and major surgical procedures. PPIs work by irreversibly blocking an enzyme called H+/K+ ATPase, which controls acid production. Examples include medications like esomeprazole, pantoprazole and lansoprazole. Most clients are not started on full-liquid diets that include milk products until their bowel sounds return. Sitting the client in high-Fowler position might help with acid reflux, but to prevent stress ulcers, a PPI is required. Pain medication for gastroesophageal reflux disease will not prevent stress ulcer formation.

Rationale: The presence of HBsAG would suggest that this woman is in the prodromal phase of hepatitis B infection. A normal serum acetaminophen level does not preclude toxicity if the drug is taken over a period of time. Steatosis is fatty infiltration of the liver. Steatosis is often but not exclusively an early histological feature of alcoholic liver disease (therefore, with chronic alcohol abuse, the nurse should expect the client may have steatosis). Drinking heavily without eating can block your liver from releasing stored glucose into your bloodstream, causing hypoglycemia.

Rationale: Complications of portal hypertension include ascites, splenomegaly, and hepatic encephalopathy. Following paracentesis to remove ascitic fluid, a volume expander such as albumin is usually administered to maintain the effective circulating volume. Furosemide and bumetanide are diuretics which decrease circulating fluid volume. Epoetin alfa stimulates red blood cell production and ultimately increases O ₂ carrying capacity.

Rationale: Obstructive jaundice occurs when bile flow is obstructed between the liver and the intestine. Among the causes are strictures of the bile duct, gallstones, and tumors of the bile duct or the pancreas. Conjugated bilirubin levels usually are elevated; the stools are clay colored; the urine is dark; the levels of serum alkaline phosphatase are markedly elevated; and the aminotransferase levels are increased.

Rationale: The client is asking about the connection between a low-fat diet, triglyceride levels, and weight loss. Therefore, the nurse should explain two key points: (1) triglycerides come from the fat consumed, and (2) when carbohydrates are consumed in excess of what is immediately converted to energy, the excess is converted to triglycerides in the liver. The triglycerides formed in the liver are transported mainly in low-density lipoproteins (LDLs) to the adipose tissue, where they are stored (contributing to weight gain). Exercise can help burn off excess calories but weight loss can be achieved through caloric restriction alone. The client may not need medication if the proper lifestyle interventions are implemented.

Rationale: Anemia, thrombocytopenia, and the presence of spider angiomas are characteristic of liver failure. High blood pressure, excessive clotting, fever and cardiac dysrhythmias are not common symptoms of liver failure. In liver failure, AST and ALT levels would rise, not fall.

Rationale: Ascites, anorexia, and bleeding tendencies due to neurological effects and epigastric pain are common accompaniments to cirrhosis. Ascites occurs when the amount of fluid in the peritoneal cavity is increased, and is a late-stage manifestation of cirrhosis and portal hypertension. Epigastric pain is caused by liver enlargement or peritonitis. The peritoneal fluid is seeded with bacteria from the blood or lymph or from passage of bacteria through the bowel wall. Because factors V, VII, IX, X, prothrombin, and fibrinogen are synthesized by the liver, their decline in liver disease contributes to bleeding tendencies. Fever and obesity would be less likely to exist, as the pathology is not infectious in nature and malnutrition and impaired food metabolism are common.

Rationale: Pruritus is the most common symptom of cholestasis and deficiencies in fat-soluble vitamins such as A, D, and K are frequent. Flank pain is not a noted complaint, and bile does not contribute to drug metabolism, blood filtration, or clotting factor production.

Rationale: HBIG is used as an adjunct to hepatitis B vaccine for post-exposure immunoprophylaxis to prevent HBV infections in high-risk populations. Tenofovir disoproxil fumarate plus emtricitabine is for HIV pre-exposure coverage. There is no hepatitis C vaccine available on the market yet. HAV is for hepatitis A vaccine, which is usually spread from the fecal–oral route rather than blood and body fluids.

Rationale: The client with end-stage biliary cirrhosis will have a chronic reduction in bile production, which interferes with the ability to emulsify and use fat-soluble vitamins. Due to a lack of vitamin K, the client can develop an associated risk for bleeding. Lack of vitamin D results in osteoporosis in clients and an increased risk for pathologic fractures, so the nurse should encourage vitamin D intake. This risk, combined with risk for bleeding, warrants a fall prevention program. Accumulation of bile salts and the lack of fat-soluble vitamins impairs skin integrity, so the nurse should prioritize skin care and inspection for breakdown. There is no need to encourage increased intake of fluids. Fever is not a prominent feature of end-stage biliary cirrhosis. The common antipyretics should be avoided (acetaminophen and ibuprofen).

Rationale: Ammonia is produced in the colon by the bacterial degradation of proteins and amino acids, therefore more ammonia will be produced when the bacteria has access to either a greater protein load (such as when a person has bleeding in the gastrointestinal tract) or prolonged contact with colonic contents such as occurs with constipation. Normally, ammonia diffuses into the portal circulation and is transported to the liver, where it is converted to urea before entering the general circulation and then excreted via urine. When the liver is unable to convert ammonia to urea, ammonia accumulates and affects neurologic functioning. Using lactulose to create a more acidic colonic environment (low pH) is one treatment for hepatic encephalopathy. Therefore, a high colonic pH (more alkaline colonic environment) could result in more ammonia entering the circulation. While both low albumin and sodium levels are found in clients with liver failure, these are not associated with worsening hepatic encephalopathy.

Rationale: HAV is transmitted by the fecal–oral route; it is normally self-limiting and does not result in chronic hepatitis or carrier status. A vaccine is available. Transmission of hepatitis through contact with blood and body fluids is typical with hepatitis B or C.

Rationale: Alcohol use, fever, hypotension and tachycardia are often associated with pancreatitis, as are elevated serum amylase and lipase levels. These enzymes would be unlikely to rise in cases of hepatitis, cholecystitis, or cirrhosis. The precise mechanisms whereby alcohol exerts its action are largely unknown. The capacity for oxidative and nonoxidative metabolism of ethanol by the pancreas and the harmful byproducts that result have been related to the disease process. Hepatitis C has an incubation period. Most adults who acquire the infection usually are asymptomatic. Jaundice is uncommon. Direct measurement of HCV in the serum remains the most accurate test for infection. Cirrhosis represents the end stage of chronic liver disease. The end result is liver failure that affects many organs. The clients usually have anemia, thrombocytopenia, endocrine disorders, skin lesions, azotemia and renal failure, and hepatic encephalopathy.

Rationale: NSAIDs damage the mucosal barrier, allowing hydrogen ions to damage cells of the stomach lining. They do not directly increase gastrin production or H ⁺ levels. Decreased, not increased, prostaglandin synthesis would potentially compromise the gastric surfaces.

Rationale: The pyloric sphincter prevents the backflow of gastric contents from the small intestine into the stomach and controls the rate at which gastric contents enter the small intestine. If the sphincter fails, regurgitation of bile salts and duodenal contents can damage the mucosal surface of the antrum and lead to gastric ulcers, which can in turn lead to life-threatening gastrointestinal bleeding; this should be the nurse’s priority. There would not be an increased risk for developing pancreatitis, which is associated with alcohol and certain drugs. Having the pyloric sphincter open will not result in intestinal obstruction. Jaundice is related to excess levels of bilirubin, which is not related to this condition.

Rationale: Inflammation of the small intestine is accompanied by an increase in motility, an effect that is the result of increased peristaltic waves. Segmentation waves are responsible primarily for mixing rather than moving food. Neither dilation nor inadequate slowing of passage contents are responsible for the increase in motility.

Rationale: The first layer performs numerous functions. These include production of mucus that lubricates and protects the inner surface of the alimentary canal; secretion of digestive enzymes and substances that break down food; absorption of the breakdown products of digestion; and maintenance of a barrier to prevent the entry of noxious substances and pathogenic organism. The facilitation of movement of contents of the gastrointestinal tract occurs in the third layer while holding the organs in place. Storage of fats occurs in the fourth layer.

Rationale: People with a deficiency of lactase, the enzyme that breaks down lactose, experience diarrhea when they drink milk or eat dairy products. It is doubtful the child is anxious about the calories in ice cream. Signs and symptoms of gallbladder disease usually occur in relation to high saturated fat intake. Signs and symptoms of a peptic ulcer include bloating, vomiting blood, and foul coffee ground stools.

Rationale: Cholecystokinin is responsible for inhibiting food intake as well as stimulating pancreatic enzyme secretion. Ghrelin stimulates food intake while gastrin stimulates gastric acid production and secretin inhibits it. Gastrin stimulates secretion of gastric acid and increases gastric blood flow. Secretin is secreted in the duodenum and inhibits gastric acid secretion.

Rationale: The interstitial cells of Cajal that are found in groups between the layers of smooth muscle tissue are hypothesized to function as the pacemakers. These cells display rhythmic, spontaneous oscillations in the membrane potentials, called slow waves, ranging in frequency from ~3/min in the stomach to 12/min in the duodenum. Sympathetic stimulation decreases this excitability, which results in decreased amplitude of the slow waves or abolishes them altogether. The vagus nurse responds to parasympathetic innervation. Gastrointestinal motility is enhanced because of increased vagal activity, which could cause diarrhea.

Rationale: The infant may be experiencing hypertrophic pyloric stenosis, which can occur in infants with an abnormally thick muscularis layer in the terminal pylorus. A defect in the lining of the first part of the small intestine (duodenal ulcer) is usually caused by an infection with a bacterium (germ) called Helicobacter pylori. When food is ingested and digested but not excreted, it forms a blockage in the colon. Regular bowel movements are needed in order for this not to occur. When bowel movements are irregular, constipation may result. This infant appears to be vomiting the stomach content; therefore no bowel movement is occurring since no food is being digested in the small intestines. Gastrin provides the major stimulus for gastric acid production. Its action on the lower esophageal sphincter protects the esophageal mucosa when gastric acid levels are elevated. If stomach acids reflux into the esophagus, acid irritation, and inflammation cause extensive injuries to the esophagus.

Rationale: When swallowing, the voluntary oral phase must be executed in a controlled manner to ensure the bolus of food touches the posterior wall of the pharynx and effectively initiates the pharyngeal phase, thereby moving the bolus into the esophagus and not the trachea. Having the client lean slightly forward with a chin tuck gives the client more control over when the bolus enters the area of the pharynx. Having the client at 45° would allow gravity to pull the bolus toward the pharynx, reducing the amount of control the client has in the voluntary phase. Having the client sit up after eating is to help prevent reflux, which can serve to prevent aspiration but is not related to the phases of swallowing. Feeding the client on the affected side should be done, but this will influence the oral phase, not the involuntary esophageal phase.

Rationale: Stimulation of the sympathetic nervous system is largely inhibitory, producing a decrease in intestinal motility and secretory activity. The sympathetic nervous system is innervated by adrenergic receptors, therefore blocking these receptors will increase intestinal motility and increase the risk for diarrhea. Anticholinergic medications block the autonomic nervous system, which would decrease intestinal motility and place the client at risk for constipation. Opioid analgesics also suppress gastrointestinal motility. Calcium channel blockers interfere with the influx of calcium needed to innervate smooth muscle cells, which can also slow gastrointestinal motility.

Rationale: A drug that interferes with cellular DNA synthesis will have a greater effect on cells that have a high rate of turnover, such as the GI epithelial cells in the mucosal layer. This means there could be damage to the oral mucosa, nausea, and diarrhea. Neither neurologic nor respiratory status would be affected by an antimetabolite compared to the GI mucosal layer.

Rationale: The colon, unlike the small intestine, moves contents by the simultaneous contraction of large segments. The anal sphincters control defecation rather than movements within the colon and haustrations perform mixing, not motility. Segmentation waves that are local events involving only 0.5 to 1.5 in (1.25 to 3.75 cm) of the intestine occur in the small intestine. The segmentation waves in the colon involve filling and expelling the contents of the haustra, which ensures that all portions of the fecal mass are exposed to the intestinal surface.

Rationale: The hospitalized client is at risk for malnutrition for a variety of reasons, including side effects of medications which may affect appetite. Therefore, the nurse should conduct a medication review to identify any offending medications that could be adjusted. The client should be aware of the risks of malnutrition, as motivation to eat—despite lack of appetite—may improve if the health benefits of staying nourished are known to the client. However, teaching the client about what foods he or she cannot eat will not improve the client’s nutritional status; these restrictions are a risk factor for malnutrition. Being isolated when hospitalized is a reason for decreased intake, so privacy should not be given at mealtimes; rather, socialization should be encouraged. The client is not at risk for refeeding syndrome as it is related to active treatment for existing malnutrition.

Rationale: Complete proteins most often are derived from animal sources and include milk, eggs, meats, fish, and poultry. There are a few vegetables that provide complete protein sources, including soy and quinoa. Peas, beans, nuts, seeds, and grains contain all the essential amino acids but in LESS than adequate proportions, therefore they are not complete proteins.

Rationale: Obesity is associated with significantly increased risk for osteoarthritis due to bone and joint stress. Insulin resistance and gallbladder disease are also identified consequences of obesity. Cardiac dysrhythmias are less likely to result directly from obesity, given their etiology rooted in electrical conductivity. Multiple sclerosis and other neurologic effects are also unlikely, and atelectasis is not commonly a direct effect of high levels of body fat.

Rationale: Fat cells are collectively considered a large energy-collection organ; the role of adipose tissue as an endocrine organ has also been recently elucidated. It is neither a desirable or reasonable goal to entirely rid the body of fat, given the key roles it plays in homeostasis, and brown fat is not common in postnatal life. Preadipocytes have been shown to play a role in obesity, but the condition is still primarily a consequence of energy intake exceeding output.

Rationale: A combined approach to weight loss including diet modification, exercise, and drug therapy has been shown to be successful in the treatment of obesity. In spite of a genetic component, obesity is still considered to be preventable. A reasonable rate of weight loss should be 5% to 10% of total body weight over a 6-month period. A reduction in food intake of between 500 and 1000 kcal, not a total food intake of 500 to 1000 kcal, is often necessary in the treatment of individuals with high BMIs. Pharmacotherapy and surgery are available as adjuncts.

Rationale: The presence of fat in the duodenum and nutrients in the small bowel result in the release of cholecystokinin and glucagon-like peptide-1, respectively, which suppress the feeding center located in the hypothalamus. Leptin and ketoacids are associated with the intermediate and long term regulation of food intake rather than the short-term control that would signal the end of a meal or snack.

Rationale: A BMI of 31 is classified as obese, and the client faces a risk of hypertension, hyperlipidemia, type 2 diabetes, coronary heart disease, and other health problems. While BMI is a valid instrument, other data sources are needed to supplement this value clinically. Environment and lifestyle factors are a greater contributor to obesity than genetics. Reducing weight from obese even to overweight offers health benefits, as higher BMIs are associated with higher morbidity and mortality.

Rationale: A waist-hip ratio greater than 1.0 in men and 0.8 in women indicates upper body or central [abdominal] obesity. Upper body obesity is referred to as being shaped like an apple. Waist circumference measures mostly subcutaneous and intra-abdominal adipose tissue. In males, a waist circumference greater than 40 inches (or 35 inches in females) is associated with increased health risk.

Rationale: Weight loss surgery should be limited to individuals with a BMI greater than 40 or those with a BMI greater than 35 with comorbid conditions in whom medical therapy has failed. Calorie reduction is appropriate for anyone with a BMI of 25 to 29.9 plus two risk factors (in this case, type 2 diabetes and hypertension). Prescription drug therapy can be considered for those with a BMI of 30 or more, and increased physical activity — although it does not lead to significant weight loss — helps prevent further weight gain and reduces cardiovascular and diabetes risk beyond that achieved by weight loss alone.

Rationale: Ill individuals are prone to disruption in protein balance, in which protein breakdown exceeds protein rebuilding. Protein mass is lost from the liver, gastrointestinal tract, kidneys, and heart. As protein is lost from the liver, hepatic synthesis of serum proteins decreases and decreased levels of serum proteins are observed. Autoimmune processes, hypoxia, and malabsorption as a result of metastases are unlikely factors.

Rationale: Non-exercise activity thermogenesis includes the energy expended in maintaining posture and in activities such as fidgeting. People with increased NEAT may have less fat gain than those with decreased NEAT. Sympathetic stimulation causes brown fat to generate more heat. Research shows obese clients with excess caloric intake have increased sympathetic activity. Proteins, not carbs, increase metabolic rate more significantly.

Rationale: The type of edema that occurs when treating malnutrition is considered benign. This dependent edema results from sodium reabsorption. It is treated by elevation of the dependent area and modest sodium restrictions—so the nurse should elevate the client’s feet. Diuretics should not be requested as they are ineffective and may aggravate electrolyte deficiencies. While it is reasonable to monitor the client’s albumin, weight ,and urine output as part of the routine assessments in this client, these factors will not factor heavily in the treatment of this benign, and expected, edema.

Rationale: Dry, cracked lips and poor skin turgor is associated with dehydration/fluid volume deficit due to vomiting. Dental abnormalities are associated with high acid content of the vomitus. Esophagitis, dysphagia, and esophageal stricture are common after frequent high acid vomitus content. Painless enlargement of the parotid gland due to vomiting is also common in bulimia nervosa clients. Fruity breath and labored, deep, gasping respirations are DKA signs/symptoms primarily caused by undiagnosed or undertreated diabetes.