# The nurse observes an intake visit for a client with PTSD symptoms. Which actions require follow-up? Highlight the actions that undermine safety, trust, or collaborative treatment. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=495946&lang=en > language: en > subject: Mental Health Concepts > category: PSI ## Question The nurse observes an intake visit for a client with PTSD symptoms. Which actions require follow-up? Highlight the actions that undermine safety, trust, or collaborative treatment. Nurses' Notes 1510: The clinic nurse observes an intake visit for a client with nightmares and hypervigilance after a traumatic event. The interviewer begins by demanding a detailed trauma account before discussing consent. The client becomes tense and looks toward the door. The nurse then offers a seat where the client can see the exit. The nurse explains the visit steps and states that questions may be paused. The client says that a support person may join if the client chooses. At 1518, the interviewer asks permission before discussing possible trauma reminders. The client identifies crowded rooms as a trigger and practices slow breathing. The plan states that all distress should disappear after the first counseling visit. The client says this promise feels impossible and discouraging. The nurse confirms that treatment options and likely benefits will be reviewed through shared decision-making. The interviewer next starts an unsupervised exposure exercise without an agreed treatment plan. The client asks to stop, and the nurse stops the exercise. The nurse documents that the client denies current thoughts of self-harm. Before leaving, the client selects one grounding strategy to practice at home. Follow-up with a qualified trauma-focused therapist is arranged. ## Explanation Forcing a trauma narrative, promising immediate symptom resolution, and starting exposure without consent or a treatment plan require follow-up. Trauma-informed care preserves safety, realistic expectations, voice, and choice. ## In-depth explanation Quick answer Highlight demanding a detailed trauma account before consent, promising that all distress will disappear after the first visit, and starting exposure without an agreed plan. These actions remove choice, create false expectations, or risk retraumatization. Why this is correct Trauma-informed care builds physical and psychological safety through transparency, collaboration, empowerment, voice, and choice. Evidence-based trauma-focused therapy can help PTSD, but it is a structured treatment selected through clinical assessment and shared decision-making, not an improvised exercise. The nurse stops coercive or unplanned actions and reconnects the client with a qualified treatment process.[2][3] Easy analogy or mental picture Think of therapy as entering a difficult trail with a map, permission, and a trained guide. Forcing someone onto the trail or promising an instant finish removes safety and control. The map picture supports preparation but does not describe every therapy session. Memory hook Safety first, explain the path, preserve choice, use a trained plan. NCLEX decision rule When trauma care feels coercive, secretive, rushed, or improvised, think risk of retraumatization; check immediate safety, consent, client choice, clinician qualifications, and the agreed treatment plan before proceeding. Why the other choices are wrong Offering a visible exit, allowing pauses and a chosen support person, asking permission, using shared decisions, checking self-harm risk, and practicing a selected grounding skill all support safety and autonomy. They do not force disclosure or promise a cure.References - [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing - [2]SAMHSA: Trauma-Informed Approaches and ProgramsSubstance Abuse and Mental Health Services Administration - [3]VA/DoD: Management of PTSD and Acute Stress DisorderU.S. Department of Veterans Affairs and Department of Defense ## Related questions - [A client hospitalized for depression says, "My family would be better off without me." Whi…](https://mymerci.kr/pages/nclex_q.php?qn_id=393687&lang=en) - [A client with schizophrenia says, "The voices are telling me to do something bad." Which r…](https://mymerci.kr/pages/nclex_q.php?qn_id=394025&lang=en) - [A client arrives with bruises at different stages of healing. 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