Which assessment should the nurse make regarding a client who has gained 5 pounds in the last 5 days?

Prepare for the Clinical Judgment Exam 1. Master key concepts with engaging quizzes and explanations. Enhance your clinical judgment skills to excel in your exam!

The appropriate assessment to make regarding a client who has gained 5 pounds in the last 5 days is to evaluate fluid retention. A sudden weight gain can often indicate an accumulation of fluid rather than an increase in body mass due to other factors like diet. Fluid retention can be caused by various conditions such as heart failure, kidney issues, or liver problems, and evaluating it is crucial to understand the cause of the weight gain.

When assessing for fluid retention, a nurse would look for signs such as puffiness, swelling in the extremities, or other clinical indicators that might suggest excess fluid in the body. Identifying fluid retention can facilitate further investigations and management, ensuring that prompt treatment is initiated if needed.

In contrast, checking for edema, assessing dietary intake, or monitoring daily weights are also valid approaches but might not directly address the immediate need to ascertain the presence of fluid retention, which is crucial for understanding the client's condition comprehensively.

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