Finall Exam:l NSGl 320/l NSG320l (Latestl
2025/l 2026l Update)l Adultl Healthl Nursingl Il Completel Guide|l Questionsl &l Answers|l Gradel A|l 100%l Correctl (Verifiedl Solutions)-l GCU
Q:l pressurel injuries
Answer:
*mustl assessl alll patientsl onl admission RISKl FACTORS -anemia -obesity -diabetes -aging -incontinence -mentall deterioration -neurologicall disorders -decreasedl circulation -increasedl bodyl temp -immobility -lowl diastolic -pain -friction REDUCINGl RISK -skinl inspection,l cleaning,l carel forl dryl skin,l moisturel barriers -increasingl mobility -nutrition -positioning,l repositioning,l transferringl techniques,l andl turning -devicesl tol decreasel pressure:l wheelchairl pad,l foaml mattress,l transferl sheets -decreasedl exposurel tol moisturel
COMPLICATIONS
ifl leftl untreated->
-cellulitis:l bacteriall skinl infection
-chronicl infection -osteomyelitis -death -mcl isl recurrencel 1 / 4
BRADENl SCALE
-19l tol 23:l nol risk
-15l tol 18:l mildl risk
-13l tol 14:l modl risk
-lessl 9:l severe
Q:l pressurel injuriesl inl thosel wl darkl skin
Answer:
-lookl forl areasl ofl darkerl colorl thanl surroundingl tissue:l blue,l brown,l purple -naturall orl halogenl lightl whenl assessing
-feell skinl temp:l mayl bel warml initially,l thanl cool
-feell consistencyl ofl skin:l boggyl orl edematous
-askl abtl painl orl itchy
Q:l stagesl ofl pressurel injuries
Answer:
STAGEl 1 -epidermis -skinl intact,l nonl blanchablel redness STAGEl 2 -epidermisl andl dermis -partiall skinl loss,l dermisl isl exposed -bedl isl moistl andl red STAGEl 3 -epidermis,l dermis,l SQ -fulll thicknessl loss,l SQl mayl bel visible -canl havel underminingl orl tunneling STAGEl 4 -epidermis,l dermis,l SQ,l involvesl deeperl structuresl (bone,l tendon,l muscle)
Q:l pressurel injuryl interventions
Answer:
DOCUMENT
-usel pish:l pressurel injuryl scalel ofl healing
-location,l stage,l size/depth,l exudate,l infection,l type,l pain -uploadl digitall picl perl hospital 2 / 4
EDUCATE
-risksl andl causesl ofl pressurel injury
-incontinence:l cleanl rightl away,l absorbentl padsl orl briefsl
-importancel ofl positioning-neverl onl thel injury,l repositionl everyl 2l hoursl andl ifl chairl boundl everyl 1l hourl -placel cleanl dressingsl overl sterilel onesl withl nol touchl method -inspectl skinl daily -goodl nutrition ACUTE -debridement
-properl dressings:l alginates,l hydrocolloid,l foam
-stagel 2l tol 4l isl consideredl contaminated:l rememberl thatl ifl personl isl immunocompromisedl orl hasl chronicl woundsl theyl mayl notl showl signsl ofl infection -keepl thel woundl bedl moist->irrigatel wl 30l mLl syringel andl 19l g
-nutrition:l 30-35l cal/kg/dayl andl 1.25-1.5l gl protein/kg/day
>mayl needl ENl orl PN
**pressurel injuriesl typicallyl heall byl secondaryl intention
Q:l immune
Answer:
IMMUNOCOMPETENCE
bodiesl abilityl tol IDl foreignl substancel andl destroyl them
-ourl immunel systeml hasl 3l functions:
1.l defense:l bodyl protectsl froml invasionl andl destroysl foreignl substances
2.l homeostasis:l bodyl removesl damagedl cellularl material
3.l surveillance:l mutationsl arel continuouslyl occurring->destroy
TYPES
1.l innate:
-wel havel thisl atl birth,l firstl linel defense,l respondsl quick -nonl specific -neutrophilsl andl monocytesl respond
2.l acquired:
-activel acquired:l wel developl antibodiesl afterl exposurel tol anl antigen.l everyl newl exposurel wel respondl fasterl andl stronger,l occursl froml al diseasel orl vaccinel wl antigenl (likel flul vacc) -passivel acquired:l wel arel givenl thel antibodiesl ratherl thanl makingl them.l eitherl froml motherl throughl thel placental orl froml injectionl froml personl whol alreadyl hasl thel antibodiesl
IMMUNOINCOMPETENT
-resultsl inl severel infection,l cancer,l orl immunodeficiencyl disorders 3 / 4
OVERREACTIVEl IMMUNE -hypersensitivityl disordersl likel allergiesl andl autoimmunel disordersl
IMMUNOSENESCENCE
decreasedl immunel responsel thatl occursl withl aging -evidence:l mccl deathl isl bacteriall pneumonia,l higherl incidencel ofl cancer -producel lessl antibodiesl whenl givenl al vaccine -thymicl shrinkage->lessl Tl cellsl tol bel produced,l accuml ofl memoryl cellsl butl nonel forl exposurel tol newl pathogens -slowerl hypersensitivityl response
>anergy:l lackl ofl responsel tol antigen
-increasel autoantibodies:l attackl normall tissuel andl organs
-decreasel inl IL
Q:l humorall vsl celll mediatedl immunity
Answer:
HUMORALl IMMUNITY -antibodyl mediated -mainl celll isl Bl lymphocytes -whenl al pathogenl meetsl al Bl celll orl isl presentedl tol Bl celll byl macrophage/monocytel itl proliferatesl producingl antibodiesl andl memoryl cells CELLl MEDIATED -pathogensl comel acrossl Tl cells -alsol hasl memoryl cellsl
**cytokinesl arel madel byl WBCl andl actl asl messengersl bwl cellsl tol producel al responsel (ILl andl INF)
Q:l hypersensitivityl reactions
Answer:
occurl withl anl overl responsel tol anl antigenl orl anl attackl onl ownl bodyl -4l types
>1-3:l immediate
>4:l delayedl
TYPEl 1 -IgGl mediated,l r/tl humorall immunity -geneticl predisposition -allergen->productionl ofl IgGl antibody
1.l atopicl reaction:l (allergicl reaction)
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