During a mental status examination, a patient sits looking tense ...

[jjjetplane]

During a mental status examination, a patient sits looking tense and suspicious. The patient has a reddened scar on the left cheek and is wearing a torn, soiled shirt and only one shoe.
 
  Which observation about appearance has the greatest significance for the patient's current mental state? a. The patient has a reddened scar on the left cheek.
  b. The patient is wearing a torn, soiled shirt.
  c. The patient appears tense and suspicious.
  d. The patient is wearing only one shoe.

Question 2

A 37-year-old, divorced client reports a fear of intimacy because of an inability to achieve and sustain an erection. This has caused him great distress.
 
  He has become more isolated and recently broke off a budding relationship with a female coworker. When caring for this client, which factors should a nurse examine in this client's initial assessment? Select all that apply.
  A) Whether the client is taking any medications
  B) When the client got divorced and the circumstances of the divorce
  C) Whether the client uses alcohol
  D) Whether the client has any sexual fetishes

[Melissahxx]

Answer to Question 1

C
The observation of tension and suspicion indicates current stress and possible paranoia. The scar, the condition of the clothing, and the absence of a shoe are not as relevant to the patient's current mental state because they originated in a time other than the present.

Answer to Question 2

A, B, C