A nurse is caring for a client. Which of the following findings require follow-up by the nurse? Select all that apply.

A. Blood pressure: The client’s BP has risen from 150/80 mm Hg to 180/86 mm Hg. This significant increase indicates a hypertensive response likely caused by pain, anxiety, and the body's sympathetic nervous system activation during a cardiac event. B. Anxiety: The note mentions the client "appears anxious." In cardiac care, sudden anxiety or a "sense of impending doom" is a clinical indicator of myocardial ischemia and decreased cardiac output. C. Oxygen saturation: At 95%, the saturation is still within an acceptable clinical range (typically >94% for most patients without chronic lung disease). While it dropped slightly from 97%, it is not the primary red flag compared to the cardiac symptoms. D. Breath sounds: The notes explicitly state that bilateral breath sounds are clear and present throughout at both 1000 and 1200. This is a normal finding and indicates that the client has not yet developed pulmonary edema or heart failure. E. Irregular heart rate: At 1000, the pulse was regular. By 1200, it is "irregular and rapid" (112/min). New-onset irregularity and tachycardia suggest that the heart muscle is irritable due to lack of oxygen, potentially leading to dangerous dysrhythmias. F. Chest tightness: The report of chest tightness radiating to jaw, not relieved with rest is a classic hallmark of a myocardial infarction. Radiation to the jaw is a common referred pain pattern in cardiac distress.