男性，60岁，高血压病史，间断服降压药，血压波动在(160～140)/(100～90)mmHg，患者未予重视，头晕、头痛明显就服药，症状消失就减量或停药，20年吸烟史，身体肥胖多年。近3天工作过度劳累，1天来剧烈头痛、头晕、恶心，血压200/120mmHg，来医院急诊为高血压，5天后症状消失，血压恢复至140/90mmHg。
经上述护理评估后，目前患者存在的主要护理诊断为
A．知识缺乏
B．活动无耐力
C．疼痛
D．有受伤的危险
E．潜在并发症：脑血管意外
参考答案：A
解析： 该患者目前血压经治疗已经恢复到了正常水平，但是该患者确诊后间断服降压药，血压波动在160/100mmHg～140/90mmHg而未予重视，头晕、头痛明显就服药，症状稍失就减量或停药，有明显的服药依从性不佳的问题，同时患者有吸烟史，并未戒烟，此次发病也有工作劳累过度等因素。所以在患者病情好转后关键的一项护理措施是使患者了解高血压的防治，包括非药物治疗中饮食、戒烟限酒、减轻体重以及治疗方面的知识缺乏问题。
An old friend from the US whom I was looking forward to staying with , telephoned from the airport to tell me that he had arrived . I was still at the at that time , but I had got everything ready for his arrival . After letting him know where my house was，I told him that I had left the under the door--mat（门垫）. I was likely to be home rather late , I told him to go into the and help himself to food and drink . Two hours later my friend me from the house . At the moment , he said , he was listening to some of my records after having just had a truly wonderful . He had found a cooker and two eggs and had helped himself to some cold chicken from the ice box . Now , he said , he was drinking a glass of orange juice and he hoped I would him . When I asked him if he had reached the house without difficulty , he answered , “I was not able to find the key , luckily the living-room windows just by the apple tree were left open and you know what I could do .” I listened to all this in .In front of my living-room there was no apple tree at all .
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