hinkle Ch 30: Management of Patients with Hematologic Neoplasms ML7

A client is being tested for acute myeloid leukemia (AML). The nurse knows that which diagnostic test will be used as the hallmark for the diagnosis? Complete blood count Bone marrow analysis Clotting factors Alkaline phosphatase level

Bone marrow analysis Explanation: To confirm the diagnosis of AML, laboratory studies need to be performed. A bone marrow analysis shows an excess or more than 20% of blast cells which is the hallmark of the diagnosis. Clotting factors are not used to diagnose AML. The complete blood count (CBC) commonly shows a decrease in both erythrocytes and platelets but is not as specific as the bone marrow analysis. The alkaline phosphatase level measures a liver enzyme.

The nurse is discussing disorders of the hematopoietic system when a client asked about erythrocytosis. What disease will the nurse mention with a primary characteristic of erythrocytosis? polycythemia vera sickle cell disease aplastic anemia pernicious anemia

polycythemia vera Explanation: Polycythemia vera is associated with a rapid proliferation of blood cells produced by the bone marrow. In sickle cell disease, HbS causes RBCs to assume a sickled shape under hypoxic conditions. Aplastic anemia has a deficiency of erythrocytes. Sickle cell disease and the anemias do not have the characteristics of erythrocytosis.

The nurse suspects that a client has multiple myeloma based on the client's major presenting symptom and the analysis of laboratory results. What classic symptom for multiple myeloma does the nurse assess for? Bone pain in the back of the ribs Severe thrombocytopenia Debilitating fatigue Gradual muscle paralysis

Bone pain in the back of the ribs Explanation: Although patients can have asymptomatic bone involvement, the most common presenting symptom of multiple myeloma is bone pain, usually in the back or ribs. Unlike arthritic pain, the bone pain associated with myeloma increases with movement and decreases with rest; clients may report that they have less pain on awakening but the pain intensity increases during the day.

What assessment finding best indicates that the client has recovered from induction therapy? Vital signs within normal ranges Absence of bone pain No evidence of edema Neutrophil and platelet counts within normal limits

Neutrophil and platelet counts within normal limits Explanation: Recovery from induction therapy is indicated when the neutrophil and platelet counts have returned to normal and any infection has resolved. Stable vital signs, lack of edema, and absence of pain are not indicative of recovery from induction therapy.

Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets? Pancytopenia Anemia Thrombocytopenia Leukopenia

Pancytopenia Explanation: Pancytopenia may be congenital or acquired. Anemia refers to decreased red cell mass. Leukopenia refers to a less-than-normal amount of WBCs in circulation. Thrombocytopenia refers to a lower-than-normal platelet count.

Clients with multiple myeloma have abnormal plasma cells that proliferate in the bone marrow where they release osteoclast-activating factor, resulting in the formation of osteoclasts. What is the most common complication of the pathology resulting from this process? Pathologic fractures Osteoporosis Increased mobility Calcified bones

Pathologic fractures Explanation: Osteoclasts are cells that break down and remove bone cells, which results in increased blood calcium and pathologic fractures.

The hospitalized client is experiencing gastrointestinal bleeding with a platelets at 9,000/mm³. The client is receiving prednisone and azathioprine. What action will the nurse take? Teach the client to vigorously floss the teeth to prevent infections. Perform a neurologic assessment with vital signs. Use contact precautions with this client. Request a prescription of diphenoxylate and atropine for loose stools.

Perform a neurologic assessment with vital signs. Explanation: With platelets less than 10,000/mm³ there is a risk for spontaneous bleeding, including within the cranial vault. The nurse performs a neurologic examination to assess for this possibility. Though the client is receiving immunosuppressants, it is not necessary to use contact precautions with this client. Contact precautions are used with clients who have known or suspected transmittable illnesses. Diphenoxylate and atropine can cause constipation and inhibit accurate assessment of the client's gastrointestinal bleeding. If the client strains when having a bowel movement, the client could bleed even more. The client is not to floss vigorously; doing so can cause bleeding.

A nurse is caring for a client with multiple myeloma. Which nursing intervention is most appropriate for this client? Balancing rest and activity Monitoring respiratory status Preventing bone injury Restricting fluid intake

Preventing bone injury Explanation: When caring for a client with multiple myeloma, the nurse should focus on relieving pain, preventing bone injury and infection, and maintaining hydration. Monitoring respiratory status and balancing rest and activity are appropriate interventions for any client. To prevent such complications as pyelonephritis and renal calculi, the nurse should keep the client well hydrated — not restrict fluid intake.

The nurse is assisting the client with multiple myeloma to ambulate. What is the most important nursing intervention to help prevent fractures in the client? Encourage adequate nutrition. Increase mobility. Provide adequate hydration. Promote safety.

Promote safety. Explanation: Safety is paramount because any injury, no matter how slight, can result in a fracture. Mobility, hydration, and nutrition are important, but will not prevent fractures.

A client who is being treated for AML has bruises on both legs. What is the nurse's most appropriate action? Keep the client on bed rest. Ask the client whether they have recently fallen. Evaluate the client's INR. Evaluate the client's platelet count.

Evaluate the client's platelet count. Explanation: Complications of AML include bleeding. The risk of bleeding correlates with the level and duration of platelet deficiency. Major hemorrhages may develop when the platelet count drops to less than 10,000/mm3. The bleeding is usually unrelated to falling. Keeping the client on bed rest will not prevent bleeding when the client has a low platelet count. Assessment for other areas of bleeding is also a priority intervention.

A patient with acute myeloid leukemia (AML) is having hematopoietic stem cell transplantation (HSCT) with radiation therapy. In which complication do the donor's lymphocytes recognize the patient's body as foreign and set up reactions to attack the foreign host? Graft-versus-host disease Remission Bone marrow depression Acute respiratory distress syndrome

Graft-versus-host disease Explanation: Patients who undergo HSCT have a significant risk of infection, graft-versus host disease (in which the donor's lymphocytes [graft] recognize the patient's body as "foreign" and set up reactions to attack the foreign host), and other complications.

A nurse is assessing a client with multiple myeloma. Due to this condition, what will this client be at risk for? chronic liver failure. acute heart failure. hypoxemia. pathologic bone fractures.

pathologic bone fractures. Explanation: Clients with multiple myeloma are at risk for pathologic bone fractures secondary to diffuse osteoporosis and osteolytic lesions. Also, clients are at risk for renal failure secondary to myeloma proteins by causing renal tubular obstruction. Liver failure and heart failure aren't usually sequelae of multiple myeloma. Hypoxemia isn't usually related to multiple myeloma.

A client with a new onset of rib and spine pain is being evaluated for multiple myeloma. For which manifestations will the nurse assess this client? Select all that apply. Hypercalcemia Renal dysfunction Anemia Lymph enlargement Bone destructions

Hypercalcemia Renal dysfunction Bone destructions Anemia Explanation: Clinical manifestations of multiple myeloma result not only from the malignant cells themselves, but also from the abnormal protein they produce. The classic clinical manifestations of multiple myeloma are referred to as the CRAB features and include anemia, hypercalcemia, renal dysfunction, and bone destruction. Lymph enlargement is associated with lymphomas, but not with multiple myeloma.

A client has completed induction therapy and has diarrhea and severe mucositis. What is the appropriate nursing goal? Administer pain medication. Place the client in reverse isolation. Maintain nutrition. Address issues of negative body image.

Maintain nutrition. Explanation: Maintaining nutrition is the most important goal after induction therapy because the client experiences severe diarrhea and can easily become nutritionally deficient and develop fluid and electrolyte imbalance. The client is most likely not in pain at this point, and this is an intervention, not a goal.

Which statement best describes the function of stem cells in the bone marrow? They produce antibodies against foreign antigens. They produce all blood cells. They are active against hypersensitivity reactions. They defend against bacterial infection.

They produce all blood cells. Explanation: All blood cells are produced from undifferentiated precursors called pluripotent stem cells in the bone marrow. Other cells produced from the pluripotent stem cells help defend against bacterial infection, produce antibodies against foreign antigens, and are active against hypersensitivity reactions.

The nurse is teaching the client about consolidation. What statement should be included in the teaching plan? "Consolidation is the term used when a client does not tolerate chemotherapy." "Consolidation of the lungs is an expected effect of induction therapy." "Consolidation occurs as a side effect of chemotherapy." "Consolidation therapy is administered to reduce the chance of leukemia recurrence."

"Consolidation therapy is administered to reduce the chance of leukemia recurrence." Explanation: Consolidation therapy is administered to eliminate residual leukemia cells that are not clinically detectable and reduce the chance for recurrence. It is also termed post-remission therapy. It is not a side effect of chemotherapy, but the administration of chemotherapy.

The nurse is caring for a client with acute myeloid leukemia (AML) with high uric acid levels. What medication does the nurse anticipate administering that will prevent crystallization of uric acid and stone formation? Asparaginase Hydroxyurea Filgrastim Allopurinol

Allopurinol Explanation: Massive leukemic cell destruction from chemotherapy results in the release of intracellular electrolytes and fluids into the systemic circulation. Increases in uric acid levels, potassium, and phosphate are seen; this process is referred to as tumor lysis (cell destruction) syndrome. The increased uric acid and phosphorus levels make the client vulnerable to renal stone formation and renal colic, which can progress to acute renal failure. Patients require a high fluid intake, and prophylaxis with allopurinol or rasburicase to prevent crystallization of uric acid and subsequent stone formation

A client with AML has pale mucous membranes and bruises on the legs. What is the primary nursing intervention? Assess the client's pulse and blood pressure. Assess the client's skin. Check the client's history. Assess the client's hemoglobin and platelets.

Assess the client's hemoglobin and platelets. Explanation: Clients with AML may develop pallor from anemia and a tendency to bleed because of a low platelet count. Assessing the client's hemoglobin and platelets will help to determine whether this is the cause of the symptoms. This would be the priority above assessing pulses, blood pressure, history, or skin.

The nurse is teaching a client about the development of leukemia. What statement should be included in the teaching plan? "In chronic leukemia, the minority of leukocytes are mature." "Chronic leukemia develops slowly." "Acute leukemia develops slowly." "In acute leukemia there are not many undifferentiated cells."

"Chronic leukemia develops slowly." Explanation: Chronic leukemia develops slowly, and the majority of leukocytes produced are mature. Acute leukemia develops quickly and the majority of leukocytes are undifferentiated cells.

Which statement indicates the client understands teaching about induction therapy for leukemia? "I will start slowly with medication treatment." "I will need to come every week for treatment." "I know I can never be cured." "I will be in the hospital for several weeks."

"I will be in the hospital for several weeks." Explanation: Induction therapy involves high doses of several medications and the client is usually admitted to the hospital for several weeks. The treatment is started quickly and the goal is to cure or put the disease into remission.

The nurse is teaching a client with acute lymphocytic leukemia (ALL) about therapy. What statement should be included in the plan of care? "Intrathecal chemotherapy is used primarily as preventive therapy." "The goal of therapy is palliation." "Treatment is simple and consists of single-drug therapy." "Side effects are rare with therapy."

"Intrathecal chemotherapy is used primarily as preventive therapy." Explanation: Intrathecal chemotherapy is a key part of the treatment plan to prevent invasion of the central nervous system. The therapy uses multiple drugs, with many side effects. The goal of therapy is remission.

Which patient assessed by the nurse is most likely to develop myelodysplastic syndrome (MDS)? A 40-year-old patient with a history of hypertension A 72-year-old patient with a history of cancer A 52-year-old patient with acute kidney injury A 24-year-old female taking oral contraceptives

A 72-year-old patient with a history of cancer Explanation: Primary MDS tends to be a disease of people older than 70 years. Because the initial findings are so subtle, the disease may not be diagnosed until later in the illness trajectory, if at all. Thus, the actual incidence of MDS is not known.

A client presents with peripheral neuropathy and hypoesthesia of the feet. What is the best nursing intervention? Encourage ambulation. Assess for signs of injury. Keep the feet cool. Elevate the client's legs.

Assess for signs of injury. Explanation: A client with hypoesthesia of the feet will have decreased sensation and numbness. The nurse should assess for signs of injury. If the client is injured, he or she will not be able to feel it; this could lead to the development of infection. Ambulation will not help the client, and elevating the legs may make the problem worse, as blood flow to the feet would be decreased. Keeping the feet cold will also decrease blood flow.

A home care nurse is caring for a client with multiple myeloma. Which nursing interventions are appropriate for this client? Select all that apply. Delay position changes and bathing if the client is experiencing pain. Monitor renal function Instruct the client to avoid activities that may cause injury. Limit fluid intake. Assist with ambulation because exercise can worsen loss of calcium from the bone.

Delay position changes and bathing if the client is experiencing pain. Instruct the client to avoid activities that may cause injury. Monitor renal function Explanation: Pain can become quite severe. Delay position changes and bathing until analgesic has reached peak concentration level and the client is experiencing maximum pain relief. Safety is paramount because any injury, no matter how slight, can result in a fracture. The nurse assists the client with ambulation because immobility can worsen loss of calcium from the bone. The nurse provides up to 4000 mL of fluid to prevent renal damage from hypercalcemia and precipitation of protein in the renal tubules.

A client with multiple myeloma is complaining about pain. What instructions will the nurse give the client to help to reduce pain during activity? Do not lift more than 10 pounds. Limit fluids to prevent going to the bathroom. Limit activity to once a day. Stay in bed as much as possible.

Do not lift more than 10 pounds. Explanation: The client with multiple myeloma needs education about activity instructions, such as lifting no more than 10 pounds and using proper body mechanics. Braces may be needed. The client should be active and would not be instructed to stay in bed or limit activity, as he or she would become very stiff. Limiting fluids would be contraindicated; the client needs to remain well hydrated.

The nurse is interacting with a family that has been caring for a client with cancer for several months. What are the best interventions to assist in relieving caregiver stress in this family? Select all that apply. Allow family members to express feelings. Suggest the family go to church more often. Educate the family about medications and side effects. Suggest support for household maintenance. Suggest the prescription of antianxiety medications.

Educate the family about medications and side effects. Allow family members to express feelings. Suggest support for household maintenance. Explanation: Family members benefit from increased education on what to expect. Allowing family members to express their feelings has also been shown to relieve stress. Supporting the caregiver and family with help in household duties will also help the overburdened family. Antianxiety medications and church attendance have not been shown to reduce caregiver stress.

A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see? Hypermagnesemia Hypercalcemia Hyperkalemia Hypernatremia

Hypercalcemia Explanation: Calcium is released when bone is destroyed, causing hypercalcemia. Multiple myeloma doesn't affect potassium, sodium, or magnesium levels.

When assessing a female client with a disorder of the hematopoietic or the lymphatic system, which assessment is most essential? Health history, such as bleeding, fatigue, or fainting Age and gender Lifestyle assessments, such as exercise routines Menstrual history

Health history, such as bleeding, fatigue, or fainting Explanation: When assessing a client with a disorder of the hematopoietic or the lymphatic system, it is essential to assess the client's health history. An assessment of drug history is essential because some antibiotics and cancer drugs contribute to hematopoietic dysfunction. Aspirin and anticoagulants may contribute to bleeding and interfere with clot formation. Because industrial materials, environmental toxins, and household products may affect blood-forming organs, the nurse needs to explore exposure to these agents. Age, gender, menstrual history, or lifestyle assessments, such as exercise routines and habits, do not directly affect the hematopoietic or lymphatic system.

A patient with AML is having aggressive chemotherapy to attempt to achieve remission. The patient is aware that hospitalization will be necessary for several weeks. What type of therapy will the nurse explain that the patient will receive? Antimicrobial therapy Supportive therapy Induction therapy Standard therapy

Induction therapy Explanation: Despite advances in understanding of the biology of AML, substantive advances in treatment response rates and survival rates have not occurred for decades, with the exception of advances made in treating APL (see later discussion). Even for patients with subtypes that have not benefited from advances in treatment, cure is still possible. The overall objective of treatment is to achieve complete remission, in which there is no evidence of residual leukemia in the bone marrow. Attempts are made to achieve remission by the aggressive administration of chemotherapy, called induction therapy, which usually requires hospitalization for several weeks.

Which term refers to a form of white blood cell involved in immune response? Spherocyte Thrombocyte Granulocyte Lymphocyte

Lymphocyte Explanation: Both B and T lymphocytes respond to exposure to antigens. Granulocytes include basophils, neutrophils, and eosinophils. A spherocyte is a red blood cell without central pallor, seen with hemolysis. A thrombocyte is a platelet.

The nurse is administering packed red blood cell (RBC) transfusions for a patient with myelodysplastic syndrome (MDS). The patient has had several transfusions and is likely to receive several more. What is a priority for the nurse to monitor related to the transfusions? Magnesium levels Potassium levels Iron levels Creatinine and blood urea nitrogen (BUN) levels

Iron levels Explanation: For most patients with MDS, transfusions of RBCs may be required to control the anemia and its symptoms. These patients can develop iron overload from the repeated transfusions; this risk can be diminished with prompt initiation of chelation therapy (see following Nursing Management section).

The nurse cares for an older adult client with unprovoked back pain and increased serum protein. Which hematologic neoplasm does the nurse suspect the client has? Hodgkin lymphoma Chronic myeloid leukemia Non-Hodgkin lymphoma Multiple myeloma

Multiple myeloma Explanation: Any older adult with unprovoked or unexplained back pain and increased protein in the serum should be assessed for multiple myeloma. Bone pain occurs because of bone breakdown and the malignant cells of multiple myeloma increase the serum protein levels.

A client was admitted to the hospital with a pathologic pelvic fracture. The client informs the nurse that he has been having a strange pain in the pelvic area for a couple of weeks that was getting worse with activity prior to the fracture. What does the nurse suspect may be occurring based on these symptoms? Polycythemia vera Leukemia Hemolytic anemia Multiple myeloma

Multiple myeloma Explanation: The first symptom usually is vague pain in the pelvis, spine, or ribs. As the disease progresses, the pain becomes more severe and localized. The pain intensifies with activity and is relieved by rest. When tumors replace bone marrow, pathologic fractures develop. Hemolytic anemia does not result in pathologic fractures nor does polycythemia vera or leukemia.

A client with acute myeloid leukemia has a fever. What pathophysiological process does the nurse recognize is the cause of the client's fever? Neutropenia Anemia Pancytopenia Thrombocytopenia

Neutropenia Explanation: Fever and infection result from a decrease in neutrophils (neutropenia). Decreased red blood cells (anemia) cause weakness, fatigue, dyspnea on exertion, and pallor in AML. Pancytopenia, an overall decrease in all blood components, is not cause of fever in clients with AML. Decreased platelet count (thrombocytopenia) causes petechiae and bruising in AML.

The nurse is caring for a client with multiple myeloma. Why would it be important to assess this client for fractures? Osteoclasts break down bone cells so pathologic fractures occur. Osteolytic activating factor weakens bones producing fractures. Osteosarcomas form producing pathologic fractures. Osteopathic tumors destroy bone causing fractures.

Osteoclasts break down bone cells so pathologic fractures occur. Explanation: The abnormal plasma cells proliferate in the bone marrow, where they release osteoclast-activating factor. This, in turn, causes osteoclasts to break down bone cells, resulting in increased blood calcium and pathologic fractures. The plasma cells also form single or multiple osteolytic (bone-destroying) tumors that produce a "punched-out" or "honeycombed" appearance in bones such as the spine, ribs, skull, pelvis, femurs, clavicles, and scapulae. Weakened vertebrae lead to compression of the spine accompanied by significant pain. The other options are distractors for this question.

The nurse is performing an assessment on a patient with acute myeloid leukemia (AML) and observes multiple areas of ecchymosis and petechiae. What laboratory study should the nurse be concerned about? WBC count of 4,200 cells/uL Hematocrit of 38% Creatinine level of 1.0 mg/dL Platelet count of 9,000/mm3

Platelet count of 9,000/mm3 Explanation: Complications of AML include bleeding and infection, which are the major causes of death. The risk of bleeding correlates with the level and duration of platelet deficiency (thrombocytopenia). The low platelet count can cause ecchymoses (bruises) and petechiae. Major hemorrhages also may develop when the platelet count drops to less than 10,000/mm3.

The nursing instructor is discussing disorders of the hematopoietic system with the pre-nursing pathophysiology class. What disease would the instructor list with a primary characteristic of erythrocytosis? Polycythemia vera Sickle cell disease Pernicious anemia Aplastic anemia

Polycythemia vera Explanation: Polycythemia vera is associated with a rapid proliferation of blood cells produced by the bone marrow. In sickle cell disease, HbS causes RBCs to assume a sickled shape under hypoxic conditions. Aplastic anemia has a deficiency of erythrocytes. The other options do not have the characteristics of erythrocytosis.

The nurse recognizes the clinical assessment of a patient with acute myeloid leukemia (AML) includes observing for signs of infection early. What nursing action will most likely help prevent infection? Monitor the client's temperature every shift. Maintain contact precautions. Practice vigilant handwashing. Encourage increased fluid consumption.

Practice vigilant handwashing. Explanation: Infection prevention is best handled by vigilant handwashing. Monitoring the client's temperature once a shift is not often enough. The client will take precautions, but precautions are enough to prevent infections. Encouraging increased fluid consumption will not prevent infection.

The nurse is caring for a patient with Hodgkin lymphoma in the hospital and preparing discharge planning education. Knowing that this patient is at risk for the development of a second malignancy, what education would be beneficial to reduce the risk factors? (Select all that apply.) Decrease fat intake Decrease intake of antipyretic medications such as acetaminophen Smoking cessation Decrease alcohol intake Reduce exposure to excessive sunlight

Reduce exposure to excessive sunlight Smoking cessation Decrease alcohol intake Explanation: The potential development of a second malignancy should be addressed with the patient when initial treatment decisions are made. However, patients should also be told that Hodgkin lymphoma is often curable. The nurse should encourage patients to reduce other factors that increase the risk of developing second cancers, such as use of tobacco and alcohol and exposure to environmental carcinogens and excessive sunlight.

A client is awaiting test results to diagnose Hodgkin lymphoma. The nurse knows that which result is the hallmark for the diagnosis of this condition? Elevated platelet count Reed-Sternberg cells Increased basophils Misshaped red blood cells

Reed-Sternberg cells Explanation: The malignant cell of Hodgkin lymphoma is the Reed-Sternberg cell, a gigantic tumor cell that is morphologically unique and thought to be of immature lymphoid origin. These cells arise from the B lymphocyte. They may have more than one nucleus and often have an owl-like appearance. The presence of Reed-Sternberg cells is the pathologic hallmark and essential diagnostic criterion. Basophils, platelets, or red blood cells are not used to diagnose Hodgkin lymphoma.

A client with multiple myeloma reports severe paresthesia in the feet. When planning care for the client, which priority nursing diagnosis will the nurse choose? Sensory-perception disturbance Risk for falls Impaired tissue integrity Acute pain

Risk for falls Explanation: A client with paresthesia in the feet is at risk for falls due to impaired sensation. Acute pain, impaired tissue integrity, and sensory-perception disturbance are all nursing diagnoses that are appropriate for the client; however, risk for falls is priority. [reported this question for page reference not having this info]

The nurse in the oncology clinic is caring for a 42-year-old female client receiving chemotherapy with fludarabine for acute myeloid leukemia who has developed petechiae, epistaxis, and ecchymosis. Complete the following sentence by choosing from the lists of options. The nurse anticipates that the client has developed __________________ [hyperkalemia] [deep vein thrombosis] [hemorrhage] [infection] ...and that the laboratory results will reveal _______________________ [abnormal renal function tests] [electrolyte imbalances] [thrombocytopenia] [leukocytosis]

[hemorrhage] [thrombocytopenia] explanation: This client has manifestations of hemorrhage, including petechiae (pinpoint bleeding in the skin), epistaxis (nosebleeds), and ecchymosis (bruises) due to a low platelet count (thrombocytopenia) secondary to chemotherapy. Chemotherapy with fludarabine may cause bone marrow suppression with neutropenia (low neutrophil count) and thrombocytopenia (low platelet count). When the platelet count is low, the client is at risk for hemorrhage as evidenced by petechiae, epistaxis, and ecchymosis. Chemotherapy with fludarabine may cause bone marrow suppression, leading to thrombocytopenia (low platelet count) and hemorrhage. Although the client is at risk for infection, the assessment findings of petechiae, epistaxis, and ecchymoses are indicators of a low platelet count. The assessment findings do not support a diagnosis of deep vein thrombosis (DVT). Manifestations of DVT include calf pain, leg swelling, and warmth, and pain over the thrombosis. Hyperkalemia does not cause signs and symptoms of hemorrhage. Leukocytosis (a low white count) may occur following treatment with fludarabine, but it does not cause petechiae, epistaxis, and ecchymosis. Electrolyte imbalances and abnormal renal function also do not cause petechiae, epistaxis, and ecchymosis.