The nurse has reviewed the nurses' notes at 0940, vital signs at 0945, and laboratory reports at 1020.

For each assessment finding, click to specify if the finding is consistent with diabetes, pancreatitis, or hyperthyroidism. Each finding may support more than one disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

A. Apply heating blanket as needed: Fever can worsen intracranial pressure (ICP) by increasing metabolic demand. Instead, cooling measures such as antipyretics or a cooling blanket should be used to maintain normothermia and prevent further ICP elevation.

B. Position the head of bed greater than 45°: Elevating the head of the bed slightly (30–45°) promotes venous drainage and reduces ICP. However, excessive elevation (>45°) may decrease cerebral perfusion pressure (CPP), leading to inadequate brain oxygenation.

C. Administer laxatives rectally: Rectal administration can stimulate the vagus nerve and increase ICP. Oral or IV stool softeners should be preferred to prevent straining, which can further elevate ICP.

D. Decrease stimulation in environment: Reducing noise, dimming lights, and minimizing disturbances help prevent spikes in ICP by decreasing sensory overload and stress. A calm environment supports cerebral oxygenation and prevents further elevation of ICP.

A. Apply an ice pack to the client's knee: Ice application helps reduce pain and inflammation by decreasing swelling around the surgical site. Cold therapy also numbs nerve endings, providing pain relief for clients after knee arthroplasty.

B. Place pillows under the client's knee: Elevating the knee with pillows can promote flexion contractures and is generally avoided after knee arthroplasty. Instead, the leg should be kept extended and supported to encourage proper alignment and prevent complications.

C. Perform range-of-motion exercises to the client's knee: While range-of-motion exercises are important for rehabilitation, they should be done at scheduled times and not during episodes of acute pain, as they could exacerbate discomfort.

D. Gently massage the area around the client's incision: Massaging near the incision site is not recommended, as it could disrupt healing tissue, increase pain, and pose a risk of infection.