NCLEX PN Practice Tests Practice Question
The nurse is giving home care to an elderly client with angina pectoris and Type 2 diabetes mellitus. Which observation is of most concern and should be reported immediately?
Correct Answer: A
Rationale: Option A raises immediate concern as it indicates a potential worsening of the client's angina pectoris, suggesting that the heart may not be receiving adequate blood flow during exertion. This symptom, especially when coupled with a recent episode, could indicate an increased risk of a cardiac event.
Option B, while noteworthy, pertains to skin changes that are common in aging and diabetes, typically requiring monitoring rather than urgent intervention.
Option C, an ingrown toenail, is also significant but usually manageable unless it leads to infection, which is not indicated here.
Option D, shortness of breath when climbing stairs, is concerning but may be less urgent than the recent chest discomfort, as it could relate to deconditioning rather than an acute cardiac issue.
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