Real Exam-Based Questions and Verified Answers with

NCLEX Nursing Health Assessment Mastery | 2025/2026 Edition Real Exam-Based Questions and Verified Answers with Rationales | 100% Accuracy | 90 Q&A | Graded A+ | Master Patient Assessment for NCLEX Success Introduction This resource includes 90 verified NCLEX-style questions and rationalized answers covering critical areas of health assessment including head-to-toe physicals, vital signs, neurological checks, respiratory and cardiac evaluation, skin integrity, and cultural competence. Aligned with the 2025/2026 NCLEX-RN & NCLEX-PN frameworks, this collection reinforces clinical decision-making and patient safety in health assessments.Answer Format All correct answers are clearly marked in bold and green and include concise rationales to support concept mastery and NCLEX readiness.

Questions (1–90 of 90)

• A nurse is performing a head-to-toe assessment on a patient. Which

action should the nurse perform first?

a) Check the patient's blood pressure

b) Inspect the skin for lesions

c) Introduce themselves and explain the procedure

d) Auscultate lung sounds

c) Introduce themselves and explain the procedure

Rationale: Establishing rapport and explaining the procedure promotes patient comfort and trust, ensuring a therapeutic interaction before physical assessment begins.

• A patient’s oral temperature is 38.5°C (101.3°F). What is the nurse’s

priority action?

a) Administer an antipyretic immediately

b) Assess for signs of infection

c) Notify the healthcare provider 1 / 3

d) Apply a cooling blanket

b) Assess for signs of infection

Rationale: A fever may indicate infection. The nurse should assess for symptoms such as chills, tachycardia, or localized redness to determine the cause before taking further action.

• During a neurological assessment, the nurse notes the patient has a

Glasgow Coma Scale (GCS) score of 12. What does this indicate?

a) Normal neurological function

b) Mild neurological impairment

c) Severe neurological impairment

d) Coma state

b) Mild neurological impairment

Rationale: A GCS score of 12 indicates mild neurological impairment, as scores range from 3 (deep coma) to 15 (fully alert).

• When assessing a patient’s respiratory status, the nurse notes a

respiratory rate of 28 breaths per minute. What is the most appropriate action?

a) Document the finding as normal

b) Assess for signs of respiratory distress

c) Administer supplemental oxygen

d) Notify the respiratory therapist

b) Assess for signs of respiratory distress

Rationale: A respiratory rate of 28 is tachypnea (normal is 12–20 breaths/min). The nurse should assess for symptoms like dyspnea, cyanosis, or use of accessory muscles.

• A nurse is assessing a patient’s heart sounds and hears an S3 gallop.

What condition might this finding indicate?

a) Heart failure

b) Mitral valve prolapse

c) Hypertension

d) Atrial fibrillation

a) Heart failure

Rationale: An S3 gallop is often associated with heart failure, indicating fluid overload and decreased cardiac compliance. 2 / 3

• A patient reports pain when the nurse palpates their abdomen. Which

quadrant should the nurse assess last to minimize discomfort?

a) Right upper quadrant

b) Left upper quadrant

c) Right lower quadrant

d) The quadrant where pain is reported

d) The quadrant where pain is reported

Rationale: To minimize discomfort, the nurse should assess the painful area last to avoid triggering guarding or tension in other areas.

• During a skin assessment, the nurse notes a stage II pressure ulcer.

What is the defining characteristic of this stage?

a) Full-thickness skin loss

b) Partial-thickness skin loss with a shallow open ulcer

c) Exposed muscle or bone

d) Intact skin with non-blanchable redness

b) Partial-thickness skin loss with a shallow open ulcer

Rationale: A stage II pressure ulcer involves partial-thickness skin loss, presenting as a shallow open ulcer or blister.

• A nurse is assessing a patient’s pupil response. Which finding

indicates a neurological concern?

a) Pupils equal and reactive to light

b) Pupils constrict when light is shone

c) One pupil is dilated and non-reactive

d) Both pupils are 3 mm in size

c) One pupil is dilated and non-reactive

Rationale: A dilated, non-reactive pupil may indicate increased intracranial pressure or neurological damage, requiring immediate attention.

• A patient from a different cultural background refuses eye contact

during the assessment. What is the nurse’s best response?

a) Insist on maintaining eye contact for better communication

b) Document the behavior as non-compliant

c) Respect the patient’s cultural norms and continue the assessment

• / 3