# 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. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617356&lang=en > language: en > subject: Sensory/Perceptual Alterations > category: PSI ## Question 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. Condition Select 1 Acute delirium Panic attack Trauma-triggered flashback Acute psychotic episode Actions to take Select 2 Place a hand on the client's shoulder to offer comfort State the client's name, the date, and the location Ask the client to describe the combat memory in detail Guide the client to name objects visible in the room Request a prescribed PRN dose of IM haloperidol Parameters to monitor Select 2 Self-rated distress (0–10) Confusion Assessment Method score Orientation to place and time Temperature Capillary blood glucose ## Explanation An abrupt loss of present orientation that begins the moment a combat-like sound occurs, in a client who was oriented 30 minutes earlier with normal temperature and glucose and no new drugs, is a trauma-triggered flashback rather than delirium or psychosis. The nurse re-orients calmly by name, date, and place and uses sensory grounding. Distress rating and orientation show whether the client is returning to the present. ## In-depth explanation 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. References 1VA National Center for PTSD — Managing PTSD symptoms: strategiesCalm orientation to the present, grounding, and avoiding sudden touch during re-experiencing 2NIMH — Post-Traumatic Stress DisorderFlashbacks as re-experiencing symptoms triggered by reminders of trauma 3SAMHSA — Trauma-informed approachesSafety, choice, and avoidance of retraumatization in care ## Clinical scenario Scenario A veteran with PTSD who was fully oriented 30 minutes earlier re-experiences combat immediately after a loud hallway noise, with autonomic arousal and loss of present-moment orientation. ## Key concepts - **Flashback** — A re-experiencing symptom in which a trauma memory feels as if it is happening now. - **Grounding** — A technique that redirects attention to present sensory details to reduce dissociation. - **Trauma-informed care** — An approach emphasizing safety, choice, and avoiding retraumatization. ## Related questions - [A 38-year-old veteran with documented post-traumatic stress disorder is hospitalized for c…](https://mymerci.kr/pages/nclex_q.php?qn_id=617415&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=617356&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=617356&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=617356&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=617356&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=617356&lang=vi) --- More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en) _For study reference only. 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