The nurse is caring for a patient who had a serious head injury.
The patient has recovered enough to be transferred to a rehabilitation facility.
Which of the following rehabilitation goals would be most appropriate for the patient?

Choice A rationale

A decreased level of consciousness indicates possible intracranial hemorrhage, a complication of thrombolytic therapy. Altered mental status may result from brain bleeding disrupting normal neural function.

Choice B rationale

Elevated blood pressure and headache suggest intracranial hemorrhage, as the rise in intracranial pressure often accompanies vascular disruption and neurogenic pain.

Choice C rationale

Vomiting and persistent nausea can signal intracranial hemorrhage, as blood irritating brain tissue and increasing pressure stimulates the emetic center in the medulla.

Choice D rationale

Positive Babinski's sign is associated with upper motor neuron lesions but is not a direct indicator of thrombolytic therapy complications such as intracranial bleeding.

Choice E rationale

Fever and cardiac dysrhythmias do not directly indicate thrombolytic therapy complications. Dysrhythmias may stem from electrolyte disturbances or infections unrelated to hemorrhage.

Choice A rationale

Detached retina typically does not present with sharp, stabbing pain. Instead, patients experience painless symptoms like vision abnormalities due to separation of the retina from supporting tissue.

Choice B rationale

Total vision loss is rare with a detached retina unless extensive damage occurs. Partial visual disruption, such as curtain-like vision loss, is a hallmark symptom.

Choice C rationale

A curtain-like loss of vision arises from retinal detachment, disrupting visual fields as the retina separates from its vascular supply and neural connections.

Choice D rationale

Yellow sclera discoloration is associated with jaundice due to bilirubin accumulation, unrelated to retinal detachment pathology, which affects visual symptoms and not scleral appearance.