100+ of the most common Head to Toe Assessment Questions with Elaborated Answers seen on the NCLEX® The Complete Head to Toe Assessment Nursing Bundle Flashcards Updated 2025 Version.

General Assessment Principles Q1: What is the primary purpose of performing a comprehensive health assessment? A) To diagnose diseases B) To establish a baseline for future assessments C) To prescribe medications D) To determine the patient's financial status Answer: B) To establish a baseline for future assessments Elaboration: A comprehensive health assessment helps to gather baseline data about the patient’s health status, which is essential for comparison in future assessments and for planning care. Neck and Cardiovascular Assessment Q2: During a cardiovascular assessment, the nurse notes a 3/6 systolic ejection murmur at the left sternal border. What does this finding suggest? A) Aortic stenosis B) Mitral regurgitation C) Normal variation D) Atrial septal defect Answer: C) Normal variation Elaboration: A 3/6 systolic ejection murmur can often be a normal finding, particularly in younger patients. However, the nurse should consider further evaluation based on the patient's history and other findings. Respiratory Assessment Q3: Which assessment finding would indicate the presence of respiratory distress? A) Bradypnea B) Use of accessory muscles C) Decreased respiratory rate D) Clear lung sounds Answer: B) Use of accessory muscles Elaboration: The use of accessory muscles indicates that the patient is struggling to breathe and is a sign of respiratory distress. Other signs include increased respiratory rate, nasal flaring, and cyanosis. Abdomen and Gastrointestinal Assessment Q4: A nurse palpates the abdomen and notes that it is distended and tender in the left lower quadrant. What condition might this suggest? A) Appendicitis B) Pancreatitis C) Diverticulitis D) Cholecystitis Answer: C) Diverticulitis Elaboration: Left lower quadrant pain and tenderness, along with abdominal distension, can indicate diverticulitis, which involves inflammation of diverticula in the colon. Musculoskeletal Assessment Q5: When assessing range of motion in a patient’s knee, the nurse notes limited flexion. What is the most appropriate nursing action? A) Document the finding and continue with the assessment B) Ask the patient to try harder to bend the knee C) Notify the healthcare provider immediately D) Assess the other knee for comparison Answer: D) Assess the other knee for comparison Elaboration: It is essential to compare findings bilaterally to determine if the limitation is a normal variation or indicative of an underlying issue. Neurological Assessment Q6: A patient is found to have a Glasgow Coma Scale (GCS) score of 12. What does this indicate? A) Mild coma B) Moderate impairment C) Full consciousness D) Severe coma Answer: B) Moderate impairment Elaboration: A GCS score of 12 suggests moderate impairment, indicating that the patient may have a decreased level of consciousness but is still able to respond to stimuli. Integumentary Assessment Q7: What skin assessment finding is most concerning for the development of pressure ulcers? A) Pink, intact skin B) Non-blanchable redness over a bony prominence C) Dry, scaly skin D) Warm skin temperature Answer: B) Non-blanchable redness over a bony prominence Elaboration: Non-blanchable redness indicates that tissue damage has begun, suggesting the potential development of a pressure ulcer, requiring immediate intervention. Assessment of Vital Signs Q8: What vital sign change would most likely indicate hypovolemia? A) Elevated temperature B) Bradycardia C) Tachycardia D) Increased blood pressure Answer: C) Tachycardia Elaboration: Tachycardia is a compensatory mechanism in response to hypovolemia as the body attempts to maintain adequate cardiac output despite low blood volume. Psychosocial Assessment Q9: During a psychosocial assessment, the nurse observes that a patient avoids eye contact and speaks softly. What might this behavior indicate? A) High self-esteem B) Anxiety or depression C) Cultural differences D) Assertiveness Answer: B) Anxiety or depression Elaboration: Avoiding eye contact and speaking softly can be signs of anxiety or depression. These behaviors may suggest the patient feels uncomfortable or lacks confidence in social interactions. Final Assessment Considerations Q10: Which of the following is a crucial step in the nursing process after completing an assessment? A) Diagnosis B) Discharge planning C) Documentation D) Medication administration Answer: C) Documentation Elaboration: Documentation is essential following an assessment as it ensures accurate communication of findings and supports continuity of care. Proper documentation also serves as a legal record of the patient’s status.