# A client admitted after a traumatic assault startles when staff close the room door and touch the client without warning. The client says, ‘I need to know what is going to happen.’ Complete the therapeutic-environment statement.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=525988&lang=en  
> language: en  
> subject: Therapeutic Environment  
> category: PSI

## Question

A client admitted after a traumatic assault startles when staff close the room door and touch the client without warning. The client says, ‘I need to know what is going to happen.’ Complete the therapeutic-environment statement.

The nurse should first ::선택::close the door without explanation so the client becomes accustomed to ittell the client that staff cannot adjust routinesask what helps the client feel safe and identify feasible preferencesbegin seclusion whenever the client startles, then ::선택::explain the next step and obtain permission before nonemergency touchapproach from behind to avoid prolonged anticipationavoid telling the client who will enter the roompromise that the client will control every clinical decision, and maintain ::선택::frequent unexpected room changespredictable routines, transparent boundaries, and realistic choicesroutine coercion to increase compliancesilence about schedule changes until they occur.

## Explanation

A trauma-informed environment emphasizes safety, trustworthiness, transparency, collaboration, and voice and choice. The nurse asks what helps the client feel safe, explains who will enter and what will happen before approaching or touching, offers realistic choices, and maintains predictable routines and boundaries. Surprise touch, unexplained closed doors, threats, and unnecessary coercion can reproduce loss of control and should be avoided when no immediate danger requires a restrictive intervention.

## In-depth explanation

Correct Answer
Ask about the client's safety preferences, explain before approaching or touching, and create a predictable plan with realistic choices and the least coercion.

Why It Fits
Predictability and shared control reduce retraumatization and support engagement in care.

Clinical Picture
Because the client is not presenting an immediate danger, restrictive measures are not justified as a routine response to startle or fear.

Memory Link
Safety is explained, choice is offered, surprises are reduced.

NCLEX Rule
A therapeutic milieu should increase safety and agency, not demand compliance through avoidable control.

Why the Alternatives Fail
Unexpected touch and unexplained restriction can intensify a trauma response. Promising unlimited choice is unrealistic, but offering bounded choices and transparent expectations is therapeutic.

Source
1SAMHSA Trauma-Informed Approaches and Programs
2SAMHSA Practical Guide for a Trauma-Informed Approach
32026 NCLEX-RN Test Plan

## Clinical scenario

There is no immediate safety threat requiring emergency restraint or seclusion. The nurse can modify routine interactions to increase physical and psychological safety and reduce retraumatization.

## Key concepts

- **Trauma-Informed Care** — An approach that recognizes trauma effects, responds with supportive practices, and works to resist retraumatization.
- **Psychological Safety** — A sense that interactions and surroundings are predictable, respectful, and not threatening or humiliating.
- **Retraumatization** — A renewed trauma response triggered by experiences that recreate fear, powerlessness, or loss of control.

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