# A hospitalized client with posttraumatic stress disorder is experiencing a flashback without threatening self or others. For each nursing response, identify whether it is appropriate now or unsafe.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=546628&lang=en  
> language: en  
> subject: Crisis Intervention  
> category: PSI

## Question

A hospitalized client with posttraumatic stress disorder is experiencing a flashback without threatening self or others. For each nursing response, identify whether it is appropriate now or unsafe.

|  | Appropriate now | Unsafe |
| --- | --- | --- |
| Approach calmly within the client's view and state the current place and time |  |  |
| Ask the client to name something seen, heard, and felt in the room |  |  |
| Reduce the triggering noise and remain present while reassessing |  |  |
| Touch the client's shoulder without warning to force orientation |  |  |
| Require a detailed account of the traumatic event during the flashback |  |  |
| Apply restraints immediately although there is no imminent danger |  |  |

## Explanation

During a flashback, the nurse helps the client reconnect with the present environment while preserving safety and control. A calm approach within view, brief orientation to place and time, and simple questions about current sights, sounds, or touch can support grounding. Reducing unnecessary noise and remaining present are appropriate. Unexpected physical contact, demanding a detailed trauma account, or restraining a client who presents no immediate danger may intensify the threat response and cause retraumatization.

## In-depth explanation

Correct Answer
Use calm present-focused grounding and reduce stimuli; avoid surprise touch, forced disclosure, and unnecessary restraint.

Why It Fits
The client is responding to a trauma reminder as though it were present but is not violent or self-destructive.

Clinical Picture
Grounding redirects attention to the current sensory environment and should be stopped or adjusted if it increases distress.

Memory Link
Here, now, safe, and no surprise touch.

NCLEX Rule
Trauma-informed crisis care maximizes present safety, choice, predictability, and the least coercive effective response.

Why the Alternatives Fail
Touching without warning, demanding trauma details, or applying restraint without a safety indication can intensify fear and undermine trust.

Sources
1VA National Center for PTSD Grounding Strategies
2VA PTSD Clinical Considerations
3NCSBN 2026 NCLEX-RN Test Plan

## Clinical scenario

Behavioral health unit
A loud overhead sound triggers the client to crouch beside the bed and repeatedly say, “Incoming.” The client appears frightened and briefly does not recognize the room. No weapon is present, and the client is not attempting self-harm or aggression.

## Key concepts

- **Flashback** — An intrusive experience in which a person feels or acts as though a traumatic event is occurring again.
- **Grounding** — A present-focused technique that directs attention to immediate sensory information and current safety.
- **Retraumatization** — Renewed distress caused when care recreates elements of powerlessness, threat, or loss of control associated with prior trauma.

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