A 34-year-old veteran with post-traumatic stress disorder is admitted for cellulitis of the left leg. At 1000 the client was alert, oriented to person, place, and time, and joking with staff. Temperature is 37.2°C (99.0°F), and capillary glucose at 0930 was 104 mg/dL. No new medications have been given since admission. At 1030 a metal supply cart crashes in the hallway. The client immediately crouches beside the bed, shouts "Incoming!", is diaphoretic with a heart rate of 118/min, and scans the room as if under attack. The client does not answer questions about the hospital stay and pulls away sharply when a staff member reaches toward the client's shoulder. The client has no history of hallucinations or delusional beliefs. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Quick answer
Trauma-triggered flashback; call the client by name with the date and location and guide sensory grounding; monitor self-rated distress and orientation to the present.

Why this is correct
The behavior begins instantly after a sound that resembles combat, the content ("Incoming!") is about past danger, and the client was oriented 30 minutes earlier. Delirium needs a medical driver and usually a fluctuating course; here temperature, glucose, and medications are unchanged. Calm orientation plus naming visible objects anchors the client in the present without adding threat.

Easy analogy or mental picture
The client's brain has replayed an old video over the live screen. The nurse does not argue with the video; the nurse keeps pointing at the live screen — your name, today's date, this room, the chair you can see.

Memory hook
Flashback = back in time. Bring them FORWARD: Name, Now, Notice (name, date/place, objects in the room).

NCLEX decision rule
When a behavior change follows a trauma cue in a client with PTSD and there is no new medical cause, choose grounding and orientation over sedation, touch, or trauma processing, and measure return to the present.

Why the other choices are wrong
Delirium is tempting because the client is disoriented, but there is no infection change, hypoglycemia, or new drug and onset matches the trigger, so CAM scoring, temperature, and glucose track the wrong problem. A panic attack causes fear and arousal but the person stays oriented to the present. Psychosis is unlikely without prior hallucinations or delusions, so IM haloperidol treats the wrong condition. Touching the shoulder is well meant but unexpected touch intensifies the perceived threat; asking for a detailed trauma account belongs to planned therapy, not the acute episode.