# A 38-year-old veteran with documented post-traumatic stress disorder is hospitalized for cellulitis. This morning the client was calm, oriented to person, place, and time, and the Confusion Assessment Method screen was negative. The client has no history of psychosis and has taken no new medications today. Seconds after a metal supply cart crashes in the hallway, the client crouches behind the bed, shouts "Incoming!", sweats, and scans the room as if under attack. Heart rate is 128/min. The client does not answer questions about the hospital stay and pulls away when a staff member reaches toward the shoulder. Capillary glucose is 104 mg/dL. 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=617415&lang=en > language: en > subject: Sensory/Perceptual Alterations > category: PSI ## Question A 38-year-old veteran with documented post-traumatic stress disorder is hospitalized for cellulitis. This morning the client was calm, oriented to person, place, and time, and the Confusion Assessment Method screen was negative. The client has no history of psychosis and has taken no new medications today. Seconds after a metal supply cart crashes in the hallway, the client crouches behind the bed, shouts "Incoming!", sweats, and scans the room as if under attack. Heart rate is 128/min. The client does not answer questions about the hospital stay and pulls away when a staff member reaches toward the shoulder. Capillary glucose is 104 mg/dL. 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 PTSD flashback Acute psychotic episode Actions to take Select 2 Place a hand on the shoulder to reassure the client Say the client's name calmly from within view Administer prescribed haloperidol intramuscularly Coach slow breathing into a paper bag Guide the client to name objects in the room Parameters to monitor Select 2 Presence of command auditory hallucinations Confusion Assessment Method result Capillary blood glucose Orientation to current place and date Heart rate ## Explanation A sensory trigger followed within seconds by combat behavior, autonomic arousal, and disconnection from the present, in a client with PTSD who was oriented this morning, identifies a flashback. The nurse approaches within view, uses the client's name calmly, and guides grounding to objects in the room. Orientation to the present and heart rate show the client returning to baseline. Touch, sedation, and paper-bag breathing are common but counterproductive reflexes. ## In-depth explanation Quick answer PTSD flashback triggered by a sound; say the client's name calmly from within view and guide the client to name objects in the room, then monitor orientation to the current place and date and heart rate. Why this is correct The trigger, the immediate onset, the content (combat danger), and the normal baseline earlier today all point to re-experiencing rather than a new medical or psychotic process. Grounding techniques anchor the client in present sensory detail, and a calm, visible approach avoids adding a new perceived threat. As the flashback ends, orientation returns and arousal falls. Easy analogy or mental picture Picture the brain replaying an old video on full screen: the nurse gently brings the real room back into the picture, one object at a time. Memory hook Trigger + past danger acted out now = flashback: name, view, ground; no surprise touch. NCLEX decision rule For acute distress after a trigger in a client with known trauma, use the least restrictive, trauma-informed response first and monitor return to present orientation. Why the other choices are wrong Delirium develops over hours to days and fluctuates; this client had a negative CAM screen this morning and reacted within seconds to a trigger, so a CAM result tracks the wrong problem. A panic attack causes fear and arousal, but the client stays oriented to the present, and paper-bag breathing is an outdated practice that can cause hypoxemia. There is no history of psychosis, and the content is a trauma memory, so haloperidol and hallucination checks do not fit. Unexpected touch can intensify the flashback. Glucose is already normal and does not track recovery. References 1NIMH — Post-Traumatic Stress DisorderRe-experiencing symptoms include flashbacks triggered by reminders of the trauma. 2SAMHSA — Trauma-Informed Approaches and ProgramsTrauma-informed care emphasizes safety, choice, and avoiding retraumatization. ## Clinical scenario Scenario Seconds after a loud metal crash, a veteran with PTSD who was oriented this morning crouches, shouts a combat warning, sweats, cannot engage with present questions, and pulls away from touch. ## Key concepts - **Flashback** — A dissociative reaction in which a person feels or acts as if a traumatic event is recurring. - **Grounding** — Techniques that direct attention to present sensory details to reduce dissociation. - **Trauma-informed care** — An approach that emphasizes safety, choice, and avoidance of retraumatization. ## Related questions - [A 34-year-old veteran with post-traumatic stress disorder is admitted for cellulitis of th…](https://mymerci.kr/pages/nclex_q.php?qn_id=617356&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=617415&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=617415&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=617415&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=617415&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=617415&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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