A combat veteran receives outpatient care for post-traumatic stress disorder with nightmares, intrusive memories, and hypervigilance. Which nursing actions are appropriate? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Trauma-focused psychotherapies, including prolonged exposure, cognitive processing therapy, and EMDR, have the strongest evidence for PTSD (Choice 2). Assess suicide risk directly at each encounter and escalate to a validated structured assessment and safety response when indicated (Choice 3). Sertraline is an evidence-supported medication; teach that benefit takes several weeks and monitor early adverse effects and suicidal thinking (Choice 4). Permission, choice, predictability, and explanation reduce retraumatization (Choice 5). During a flashback, calm present-time orientation and sensory grounding can reduce disconnection from the current environment (Choice 6). Permanent avoidance maintains PTSD; exposure work should occur gradually within evidence-based treatment rather than through forced confrontation or indefinite avoidance (Choice 1).
Clinical Judgment PTSD care layers trauma-informed communication + flashback grounding + SSRI + suicide screening + trauma-focused psychotherapy. The big NCLEX trap is permanent avoidance — sounds compassionate but worsens the disorder.
Memory Tip Flashback grounding = 5-4-3-2-1 (see-touch-hear-smell-taste). First-line drugs = SSRIs (sertraline, paroxetine). Avoid benzodiazepines — they blunt exposure response and risk dependence.
KR vs US Korean culture often favors quiet endurance after trauma; NCLEX-RN expects the nurse to actively offer evidence-based therapies and to screen for suicide and self-harm at every visit, regardless of how stoic the client appears.
Clinical Practice GuideVA/DoD and APA PTSD guidelines: first-line is trauma-focused psychotherapy (prolonged exposure, cognitive processing therapy, EMDR) followed by SSRIs (sertraline, paroxetine) or venlafaxine. Prazosin is used for trauma nightmares. Benzodiazepines are not recommended — they impair exposure learning and carry dependence risk. SAMHSA trauma-informed care principles: safety, trustworthiness, peer support, collaboration, empowerment, cultural responsiveness.
CautionCommon NCLEX traps: indefinite trigger avoidance, benzodiazepine PRN as primary therapy, and missed suicide screening. Remember: avoidance feels safe but maintains PTSD — recovery requires guided exposure plus skills.
PTSD (Post-Traumatic Stress Disorder) — DSM-5 disorder following exposure to actual or threatened death, serious injury, or sexual violence, with symptoms lasting more than 1 month in four clusters: intrusion (flashbacks, nightmares), avoidance, negative changes in cognition or mood, and hyperarousal. Lifetime prevalence about 6 percent in the United States. NCLEX exam tip: PTSD differs from acute stress disorder, which has the same picture but lasts 3 days to 1 month.
Trauma-Informed Care — SAMHSA-defined approach with six principles: safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment and choice, cultural and historical responsiveness. Practical nursing actions include asking permission before touch, offering choices, narrating procedures, and avoiding language that re-traumatizes. NCLEX exam tip: trauma-informed care is universal — apply it to all clients, not only diagnosed PTSD.
Flashback Grounding (5-4-3-2-1) — Sensory grounding technique used during flashbacks or dissociation: name 5 things you see, 4 you can touch, 3 you can hear, 2 you can smell, 1 you can taste. Reorient the client with name, current date, and location, and use a calm voice in the present tense. NCLEX exam tip: during a flashback the priority is grounding to the present, not exploring the trauma content.