NCLEX Cardiac

Instructions:

• Answer 50 questions in 15 minutes.
• If you are not ready to take this test, you can study here.
• Match each statement with the correct term.
• Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. What should be checked in a patient on a beta blocker?
4th left intercostal space lower sternal border
Limit the size of the infarction is the goal. Treatment= thrombolytic therapy (tPA) initiated within 6 hours of the first symptoms= standard treatment.
Protamine Sulfate
Pulse before and after giving.


2. What is labile hypertension?
Stroke - renal or heart failure - paraplegia secondary to compromised blood flow - or death from aortic rupture.
Thromboanglitis obliterans/ Buerger's disease= inflammatory process of arterial wall - veins - and nerves where they become blocked. It is associated with smoking/tobacco use.
BP is elevated or decreased depending on activity.
Gently insert the oropharyngeal airway by turning it upside down (into U shape) and slide it into the mouth. As continue to insert rotate it so the ends of the U turn downward into an arch shape after it transverses the oral cavity and approaches the


3. What are the S&S of cardiac tamponade?
If feel more than 3 shocks in a row or develop signs of infection at the site.
Administer 100% O2 - left trendelenburg position - heparin administered - and oral warfarin started (give heparin and warfarin together for at least 5 days).
SOB - dyspnea - anxiousness - diaphoresis - cool/clammy skin - distended neck veins - mental status changes - narrowed pulse pressure - hypotension - and faint or muffled heart sounds.
The arteries have narrowed - decreased O2 to tissues= hypoxia to cells.


4. For what disease should you do the Allen's test?

Warning: Invalid argument supplied for foreach() in /var/www/html/basicversity.com/show_quiz.php on line 183


5. What is the correct way to insert an oropharyngeal airway?
CPR should be done. No defibrillation bc no rhythm to shock (heart already depolarized).
Gently insert the oropharyngeal airway by turning it upside down (into U shape) and slide it into the mouth. As continue to insert rotate it so the ends of the U turn downward into an arch shape after it transverses the oral cavity and approaches the
The right and left ventricular pressures - cardiac output - arterial venous O2 difference - and pulmonary artery pressure.
Elderly - hypothyroidism - renal dysfunction - dehydration - HYPOKALEMIA - hypomagnesemia - or hypercalcemia. Patients with abnormal potassium levels have a higher risk because hypokalemia makes the heart more sensitive to digoxin.


6. What should you do if you are going to ventilate someone with an ambu bag?
Paroxysmal nocturnal dyspnea - elevated pulmonary capillary wedge pressure - BLOOD TINGED SPUTUM - cough - orthopnea - exertional dyspnea - cyanosis.
Thromboanglitis obliterans/ Buerger's disease= inflammatory process of arterial wall - veins - and nerves where they become blocked. It is associated with smoking/tobacco use.
Lower HOB - place patient supine - assess LOC - open airway - assess breathing - get ambu bag - put on gloves - connect tubing from O2 source - adjust flow to 10 to 15 liters. First RESCUER: PLACE APEX of MASK OVER BRIDGE of NOSE And BASE BETWEEN LOW
D/C the med and call the doctor.


7. What is the maintenance for venous access port that isn't being regularly used?
Steroid treatment or a pregnant woman who is retaining water.
Must be flushed 1x/month with heparin and between treatments.
Vitamin K (aqua myphiton)
Right atrium - TRICUSPID VALVE (tissue) - right ventricle - PULMONIC VALVE (paper) - lungs - left atrium - MITRAL VALVE (My) - left ventricle - AORTIC VALVE (Assets). Tissue PAPER MY ASSETS!


8. What is the necessary lab value to evaluate while a patient is on heparin? What is the normal value?
Assess and mark the location of the dorsalis pedis and posterior tibial pulses in affected leg - wash hands and put on sterile gloves - gown - and mask - position device - check circulation and make sure good pedal pulse is present - IMMEDIATELY REPO
PTT. Normal= 30 sec. If on anticoagulants it should be between 1 1/2 to 2 1/2 x the normal value. For PTT= 45-75 sec.
Lower HOB - place patient supine - assess LOC - open airway - assess breathing - get ambu bag - put on gloves - connect tubing from O2 source - adjust flow to 10 to 15 liters. First RESCUER: PLACE APEX of MASK OVER BRIDGE of NOSE And BASE BETWEEN LOW
Spasms of the arterioles in finger/toes (digits of hands/feet may fall off). Tx: stop smoking - avoid stress & cold - use a vasodilator (calcium channel blocker). No skiing or butcher for career.


9. What is the proper way to access and implanted venous access port (IVAP) (Mediport)?

Warning: Invalid argument supplied for foreach() in /var/www/html/basicversity.com/show_quiz.php on line 183


10. For which heart sounds should the diaphragm be used?
(1ST) BEGIN CARDIOPULMONARY RESUSCITATION (The PT. Is DYING) And NotIFY PHYSICIAN (2ND).
High pitched sounds like S1 and S2 (pericardial friction rubs - aortic/mitral regurgitation murmurs). DIAPH(high)ragm
Lower HOB - place patient supine - assess LOC - open airway - assess breathing - get ambu bag - put on gloves - connect tubing from O2 source - adjust flow to 10 to 15 liters. First RESCUER: PLACE APEX of MASK OVER BRIDGE of NOSE And BASE BETWEEN LOW
Check all junctions frequently to make sure secure - especially before patient gets out of bed - and always use tubing with twist lock connections.


11. What should you suspect for someone who post cardiac cath and percutaneous coronary intervention reporting feeling a pop in her left groin followed by a saturated dressing - swelling around site - palpable 2 inch fullness - and a bruit is present?
Assess and mark the location of the dorsalis pedis and posterior tibial pulses in affected leg - wash hands and put on sterile gloves - gown - and mask - position device - check circulation and make sure good pedal pulse is present - IMMEDIATELY REPO
This noninvasive test takes 24 hours and causes no discomfort. Electrodes are applied to your body - you need to log your activities for a 24 hour period (walking - sleeping - urinating - physical symptoms - and medications). Don't tamper with the mo
A hematoma= bleeding into the soft tissue surrounding the femoral artery access site.
GI - neuro - and cardiac. S&S= yellow/green vision - N&V - bradycardia - and anorexia.


12. How is angina treated?

Warning: Invalid argument supplied for foreach() in /var/www/html/basicversity.com/show_quiz.php on line 183


13. What are examples of calcium channel blockers?
Verapamil (calan) - diltiazem (cardizem) - nifedipine (procardia) - amlodipine (norvasc).
Fat - Air - DVT - or Amniotic
No magnets (cell phone 6 inches away from) - DO Not DRINK CAFFEINATED BEVERAGES - DO Not ENGAGE In ROUGH ACTIVITIES (FOOTBAll OR WRESTLING) - and no tight clothing over site.
Difficulty breathing - pain in midchest and shoulder - pale - nausea - and light headedness.


14. What does plan of care include?
Elevated legs - anticoagulation therapy (aggressive: generally IV heparin) - Be alert for signs of PE.
Air embolism
Having the patient supine is ideal but any position is acceptable so long as in same position for each monitoring session - locate clean and dry sensor sites on the neck (in line with earlobe) and thorax (midaxillary at xiphoid process) - connect lea
Fifth left intercostal space medial to the midclavicular line.


15. What is the hallmark clinical finding associated with pericarditis?
Elderly - hypothyroidism - renal dysfunction - dehydration - HYPOKALEMIA - hypomagnesemia - or hypercalcemia. Patients with abnormal potassium levels have a higher risk because hypokalemia makes the heart more sensitive to digoxin.
Pericardial friction rub: A high pitched squeaking or grating sound during cardiac contraction. It is typically best heard when the patient sits - leans forward - and breaths out.
This noninvasive test takes 24 hours and causes no discomfort. Electrodes are applied to your body - you need to log your activities for a 24 hour period (walking - sleeping - urinating - physical symptoms - and medications). Don't tamper with the mo
Put on gloves - remove the previous application paper and use a tissue to remove all ointment from the site to prevent overdose - squeeze the prescribed ointment in a thin layer onto a clean ruled application paper - choose an unused site on the ches


16. What is the treatment for someone in ventricular fibrillation?
(S1 - S2) Third left intercostal space
Smoking - elevated cholesterol - diabetes - hypertension - old age - and family hx of coronary artery disease.
Direct current shock (defibrillation) and IV anti - arrhythmic drugs (lidocaine - Procainamide - and Bretylium).
You need to maintain use of those devices continually except when the patient is ambulating - bathing - or during physical therapy or skin assessment.


17. What can result from left sided heart failure if left untreated?
Arterial pulse: 60-90 - Amplitude: 4+=strong and bounding - Edema: 0=none - Reflex 2+
Hematuria (tea or coca cola colored) - nosebleeds - gingival bleeding (no medicated mouth wash - flossing - or lemon glycerin swabs) - and bruising (assess for abuse w/o caregiver).
Check all junctions frequently to make sure secure - especially before patient gets out of bed - and always use tubing with twist lock connections.
Pulmonary edema


18. Should the tubing for a venous access port be included under the dressing site?

Warning: Invalid argument supplied for foreach() in /var/www/html/basicversity.com/show_quiz.php on line 183


19. What are the S&S associated with right sided heart failure?
It will take 5 mins and he/she should remain quiet for about 1 minute without talking or moving.
MONA=Magnesium sulfate - O2 - Nitroglycerin - Aspirin (mona has a heart so EKG also if select all that apply).
Fatigue - JVD - Increased peripheral venous pressure - ascites - anorexia/complaints of GI distress - cyanosis - and dependent edema.
Check for response - activate ERS - open airway head tilt chin lift - check breathing (5-10 sec) - give 2 breaths (1 sec) with visible chest rise - checks brachial pulse (5-10 sec) - locates CPR finger position - deliver 1st cycle of compressions (30


20. What are the S&S of pulmonary embolism?
Old truck driver or someone on bed rest or with pelvic trauma.
Anxiousness - restlessness - tachycardia - tachypneic - 90% SP02 - dyspnea - substernal pain - coughing - hemoptysis - and fever.
A life threatening emergency that involves a tear in the aorta's intimal layer allowing blood to flow through a false lumen creating a hematoma or false aneurysm.
Before


21. What are the indications for a chemical stress test (persantine stress test)?
A life threatening emergency that involves a tear in the aorta's intimal layer allowing blood to flow through a false lumen creating a hematoma or false aneurysm.
A hematoma= bleeding into the soft tissue surrounding the femoral artery access site.
Pericardial friction rub - chest pain (sharp and aggravated with breathing) - abnormal EKG findings - possible fever and tachycardia.
Patient who are unable to tolerate exercise stress testing.


22. How is the arterial brachial index (ABI) calculated? Who should perform this? What is normal?
It is calculated by checking the brachial BP and the ankle BP. The ankle systolic pressure is divided by the brachial systolic. The NA can perform. 0.97-1 is normal anything below indicates ischemia.
A clinician will perform echocardiogram guided pericardiocentesis with a needle or catheter to remove excess fluid in the pericardial sac.
It is noninvasive. You must not eat - smoke - or drink alcohol for 3 hours before the test. WEAR COMFORTABLE SHOES And LOOSE LIGHTWEIGHT SHORTS OR SLACKS - YOU MAY GET AN INJECTION of THAllIUM - after your blood pressure and ECG are monitored for 10-
Put on gloves - remove the previous application paper and use a tissue to remove all ointment from the site to prevent overdose - squeeze the prescribed ointment in a thin layer onto a clean ruled application paper - choose an unused site on the ches


23. What should be done during the insertion of both a CVP catheter and a swan ganz catheter?
When: using anticoagulants - liver disease - decrease in platelets (less than 150 -000) - hemophilia - using thrombolytic meds - DIC - CA - HIV - chemo - bone marrow problems - and ASA/NSAIDS.
Elderly - hypothyroidism - renal dysfunction - dehydration - HYPOKALEMIA - hypomagnesemia - or hypercalcemia. Patients with abnormal potassium levels have a higher risk because hypokalemia makes the heart more sensitive to digoxin.
It is noninvasive. You must not eat - smoke - or drink alcohol for 3 hours before the test. WEAR COMFORTABLE SHOES And LOOSE LIGHTWEIGHT SHORTS OR SLACKS - YOU MAY GET AN INJECTION of THAllIUM - after your blood pressure and ECG are monitored for 10-
Trendelenburg position for insertion. Pt holds breath to prevent air from entering sinus tract.


24. What is angina? Stable vs. unstable?

Warning: Invalid argument supplied for foreach() in /var/www/html/basicversity.com/show_quiz.php on line 183


25. What needs to be held during the placement of a femoral artery compression device?
NO NSAIDS or ASA.
Pneumothorax and will end up with chest tube to help reinflate lung.
Verapamil (calan) - diltiazem (cardizem) - nifedipine (procardia) - amlodipine (norvasc).
The patient may suffer significant blood loss or femoral nerve compression.


26. What is an acute peripheral arterial occlusion?
International Normalized Ratio measures blood clotting time and compares it to normal values. 1.0=normal. Most people on anticoagulants are 2-3.
Vascular - artery disease causing fluid to back up into the lungs.
The arteries have narrowed - decreased O2 to tissues= hypoxia to cells.
It is calculated by checking the brachial BP and the ankle BP. The ankle systolic pressure is divided by the brachial systolic. The NA can perform. 0.97-1 is normal anything below indicates ischemia.


27. What causes secondary hypertension?
Ask patient to make a tight fist - using your index and middle fingers compress both the radial and ulnar arteries to obstruct blood flow to hand - ask pt to relax hand (hand and palm should appear blanched bc flow stopped) - release pressure on ulna
Direct current cardioversion and digoxin/propranolol (inderal).
Steroid treatment or a pregnant woman who is retaining water.
An enlarged space indicates fluid accumulation in the pericardial sac.


28. What should you do when applying a femoral artery compression device?
Deep in the sternomastoid muscle - so look for pulsations in the soft tissue surrounding that area.
Assess and mark the location of the dorsalis pedis and posterior tibial pulses in affected leg - wash hands and put on sterile gloves - gown - and mask - position device - check circulation and make sure good pedal pulse is present - IMMEDIATELY REPO
Second right intercostal space
Have the patient use the val salva maneuver when the line is being removed (bear down/hold breath) to prevent air from entering where the line was and causing a PE.


29. What is a therapeutic digoxin level?
PTT. Normal= 30 sec. If on anticoagulants it should be between 1 1/2 to 2 1/2 x the normal value. For PTT= 45-75 sec.
A hematoma= bleeding into the soft tissue surrounding the femoral artery access site.
(S1 - S2) Third left intercostal space
0.5-2.0 ng/ml


30. In What time period is the greatest risk of sudden death from an MI?
In the first 72 hours!!!!!
Protamine Sulfate
A complication from a venous access device or port. It is a blockage of the superior vena cava preventing superior blood flow from reaching the heart.
Anxiousness - restlessness - tachycardia - tachypneic - 90% SP02 - dyspnea - substernal pain - coughing - hemoptysis - and fever.


31. What should you do if the PT value is 45 sec?
Constipation or MAY CAUSE ANKLES TO SWELL (call healthcare provider).
Paroxysmal nocturnal dyspnea - elevated pulmonary capillary wedge pressure - BLOOD TINGED SPUTUM - cough - orthopnea - exertional dyspnea - cyanosis.
Fat - Air - DVT - or Amniotic
D/C the med and call the doctor.


32. What landmarks should you be looking for on someone's chest?
A central line placed that measures the right atrial pressure. Normal= 4-10 cm of H20.
Aortic valve - Pulmonic valve - right ventricle - tricuspid valve - and apex or mitral valve.
Protamine Sulfate
Ask patient to make a tight fist - using your index and middle fingers compress both the radial and ulnar arteries to obstruct blood flow to hand - ask pt to relax hand (hand and palm should appear blanched bc flow stopped) - release pressure on ulna


33. What is CVP? Normal?
SOB - dyspnea - anxiousness - diaphoresis - cool/clammy skin - distended neck veins - mental status changes - narrowed pulse pressure - hypotension - and faint or muffled heart sounds.
NO because it isn't sterile so keep out.
Temporary or permanent transvenous PACEMAKER INSERTION - and if the client is symptomatic and showing S&S of decreased cardiac output - GIVE ATROPINE.
A central line placed that measures the right atrial pressure. Normal= 4-10 cm of H20.


34. How should you palpate the apical pulse?
BP is elevated or decreased depending on activity.
When not visable - place the patient in the left lateral position - ask them to exhale fully and stop breathing for a few seconds.
CPR should be done. No defibrillation bc no rhythm to shock (heart already depolarized).
MONA=Magnesium sulfate - O2 - Nitroglycerin - Aspirin (mona has a heart so EKG also if select all that apply).


35. What does the device for impedance cardiography consist of?
Only for a few hours
A monitor with four dual electrodes that are applied to the patients neck and thorax.
This noninvasive test takes 24 hours and causes no discomfort. Electrodes are applied to your body - you need to log your activities for a 24 hour period (walking - sleeping - urinating - physical symptoms - and medications). Don't tamper with the mo
A life threatening emergency that involves a tear in the aorta's intimal layer allowing blood to flow through a false lumen creating a hematoma or false aneurysm.


36. What should be done immediately for someone with PE?
Changing the way that you live is the first step. STOP SMOKING!!!! <30% FAT In DIET (don't avoid all fat) - lose weight - exercise - limit salt intake - nitro - Angioplasty (stent insertion) or CABG.
Positive Homan's sign (calf tenderness on dorsiflexion of the foot).
4th left intercostal space lower sternal border
Administer 100% O2 - left trendelenburg position - heparin administered - and oral warfarin started (give heparin and warfarin together for at least 5 days).


37. What will a leg with arterial insufficiency look like?
Hair loss - muscle mass loss - pallor when elevated - dependent rubor - and prolonged cap refill time.
Awake and alert: IV lidocaine bolus and drip Unconscious - hypotensive - or S&S of angina/CHF: Direct current cardioversion and IV Lidocaine bolus and drip.
ST segment elevation (STEMI)
Pulse before and after giving.


38. What is important to remember when taking care of patients with compression devices?
You need to maintain use of those devices continually except when the patient is ambulating - bathing - or during physical therapy or skin assessment.
Using both gloved hands - apply firm pressure just above the skin puncture site and over the hematoma to compress the area. Wait at least 15 mins before removing pressure and reassessing the site. Then notify the health care provider.
Use sterile gloves and aseptic technique - clean skin over port with alcohol or iodine - insert a 21 or 22 gauge HUBER needle (noncoring - won't break apart) attached to syringe or tubing into the middle of the port until rigid back of port is palpab
If feel more than 3 shocks in a row or develop signs of infection at the site.


39. What should you teach your patient about a cardiac catheterization?
Demand: Works PRN (when HR goes below predetermined rate) or Fixed: beats constantly at predetermined rate so no matter what heart does still beats at same rate.
Lowers BP and makes heart beat stronger. SE: flushed face.
Need for follow up blood tests - Need to take oral warfarin for at least 3 months - and to reduce current risk encourage weight loss - smoking cessation - and regular exercise.
The physician injects a local anesthetic into the site - inserts a catheter - and threads it through the artery into the left side of the heart or through a vein into the right side of the heart to your lungs. Next - a dye is injected which may cause


40. What are the 2 types of pacemakers?
Demand: Works PRN (when HR goes below predetermined rate) or Fixed: beats constantly at predetermined rate so no matter what heart does still beats at same rate.
Constipation or MAY CAUSE ANKLES TO SWELL (call healthcare provider).
Left sternal border
Feeling warm (fire) or tin can taste is expected and will pass.


41. What are the nursing interventions for a pt. with ventricular tachycardia?
Trendelenburg position for insertion. Pt holds breath to prevent air from entering sinus tract.
Second Right intercostal space.
A complication from a venous access device or port. It is a blockage of the superior vena cava preventing superior blood flow from reaching the heart.
(1st) Assess LOC - (2nd) if unconscious= begin CPR - and (3rd) Notify physician.


42. What is pulsus paradoxus?
A drop in systolic BP greater than 12 mm Hg during inspiration indicating a compromise.
Lung disease
Nitrates - Beta blockers - and Calcium channel blockers
One large emboli (smaller=better)


43. Where should you place your stethescope to find the aortic valve?
(1st) Assess the client for S&S of decreased cardiac output and Notify physician (2nd).
Fatigue - JVD - Increased peripheral venous pressure - ascites - anorexia/complaints of GI distress - cyanosis - and dependent edema.
Used in an emergency (Vfib/defib) - used with Vfib or Vtach - NO CARDIAC OUTPUT - client is unconscious - EKG monitor - NO CONSENT NEEDED - begin with 200 Joules and up to 360.
Second Right intercostal space.


44. What is pericarditis?
Ask patient to make a tight fist - using your index and middle fingers compress both the radial and ulnar arteries to obstruct blood flow to hand - ask pt to relax hand (hand and palm should appear blanched bc flow stopped) - release pressure on ulna
Totally disorganized - chaotic pattern - and no discernible waves or complexes.
Leg pain that is brought on by exercise and relieved by rest. It is characteristic of peripheral artery occlusion/ arterial insufficiency. It is dull or cramp like and consistently occurs in the same area of the leg and with same amount of distance.
An inflammation of the pericardium. It may result in MI.


45. What should you remember while taking care of someone with a peripheral arterial occlusion?
In the first 72 hours!!!!!
It will take 5 mins and he/she should remain quiet for about 1 minute without talking or moving.
It is a sterile procedure so both nurse and patient should wear a mask - arrange sterile field - remove dressing - assess the catheter insertion site for infection - put on sterile gloves - clean the site moving outwardly in a circular motion - apply
NO TED HOSE - NO SHEETS/BLANKETS - NO COMPRESSION DEVICES - (TEACH NO OPEN TOES SHOES). Lambs wool is okay!


46. What should the plan of care include for a diagnosis of activity intolerance r/t right sided HF?
Patient who are unable to tolerate exercise stress testing.
Include rest periods prior to any activity.
MRI is painless - you must remain still inside a small/noisy space. If you are claustrophobic you may need sedation. Remove all jewelry and other metal objects. If you have any shrapnel - a pacemaker - or any surgically implanted joints - pins - clip
Paroxysmal nocturnal dyspnea - elevated pulmonary capillary wedge pressure - BLOOD TINGED SPUTUM - cough - orthopnea - exertional dyspnea - cyanosis.


47. What are the S&S of superior vena cava syndrome?
Lower HOB - place patient supine - assess LOC - open airway - assess breathing - get ambu bag - put on gloves - connect tubing from O2 source - adjust flow to 10 to 15 liters. First RESCUER: PLACE APEX of MASK OVER BRIDGE of NOSE And BASE BETWEEN LOW
Feeling of fullness in head - tightness around shirt collar - or rings/jewelry that suddenly seem tight - swelling in face - hands - arms - and swollen/cyanotic lips - dyspnea - coughing - hoarseness - chest pain - hemotysis - visable collateral ches
Elevated legs - anticoagulation therapy (aggressive: generally IV heparin) - Be alert for signs of PE.
Temporary or permanent transvenous PACEMAKER INSERTION - and if the client is symptomatic and showing S&S of decreased cardiac output - GIVE ATROPINE.


48. What would make someone more at risk for digoxin toxicity?
To report to her healthcare provider if she feels a large bump in her groin - if she has groin pain unrelieved by acetaminophen - or if she develops numbness - tingling - etc. in the affected leg.
For the first month post op - do not lift more than 10 or 15 lbs. And avoid excessive pushing - pulling - or twisting.
Air embolism
Elderly - hypothyroidism - renal dysfunction - dehydration - HYPOKALEMIA - hypomagnesemia - or hypercalcemia. Patients with abnormal potassium levels have a higher risk because hypokalemia makes the heart more sensitive to digoxin.


49. Where should you place your stethescope to find the tricuspid valve?
A disease in which thrombi trap blood in the deep veins of the pelvis and legs.
PTT. Normal= 30 sec. If on anticoagulants it should be between 1 1/2 to 2 1/2 x the normal value. For PTT= 45-75 sec.
In the first 72 hours!!!!!
4th left intercostal space lower sternal border


50. If you see a NA placing a patient with DVT in sitting position with legs dependent what should you do?
INTERVENE: to control edema and decrease pain patient should be on bed rest with legs elevated six inches above heart level.
Rescuer arrives with AED - turn AED on - select proper pads and apply - clear victim to analyze - clear victim to shock/press shock - resume chest compressions after 1 shock - delivers cycle of compressions at correct rate - pause to allow other resc
Difficulty breathing - pain in midchest and shoulder - pale - nausea - and light headedness.
Varicose veins - elevate legs - weight reduction - brawny in color - ted hose - topical steroids - ulcers - and skin color changes.