A nurse is caring for a client who becomes extremely agitated. The nurse should document which of the following de-escalation techniques?

Choice A reason:
Haloperidol is not commonly associated with causing ringing in the ears (tinnitus). While tinnitus can be a side effect of some medications, it is not typically linked to haloperidol.

Choice B reason:
Urinary incontinence is not a common side effect of haloperidol. This medication is more likely to cause urinary retention rather than incontinence.

Choice C reason:
Experiencing a metallic taste is not a known side effect of haloperidol. This side effect is more commonly associated with other medications, such as certain antibiotics or chemotherapy drugs.

Choice D reason:
Increased sensitivity to the sun (photosensitivity) is a known side effect of haloperidol. Clients taking this medication should be advised to use sun protection and avoid prolonged sun exposure.

Choice A Reason:
Explaining the use of response prevention to the client is crucial as it is a primary therapeutic approach for managing obsessive-compulsive disorder (OCD). Response prevention, part of Exposure and Response Prevention (ERP) therapy, involves exposing the client to anxiety-provoking stimuli and preventing the compulsive response. This method helps the client gradually reduce their anxiety and compulsive behaviors by learning to tolerate the distress without performing the compulsive act. ERP is considered the gold standard treatment for OCD and is highly effective in reducing symptoms.

Choice B Reason:
Administering an antianxiety medication can be beneficial for managing symptoms of anxiety in clients with OCD. Common medications include selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, and fluvoxamine. However, medication alone is not the first-line treatment for OCD. It is often used in conjunction with cognitive-behavioral therapy (CBT), specifically ERP, to achieve the best outcomes. Therefore, while important, it is not the initial action the nurse should take.

Choice C Reason:
Discussing the benefits of relaxation exercises with the client can help manage anxiety symptoms associated with OCD. Techniques such as deep breathing, mindfulness meditation, and progressive muscle relaxation can be effective in reducing stress and anxiety. However, these methods are supportive measures and do not directly address the core symptoms of OCD. They are best used as complementary strategies alongside primary treatments like ERP.

Choice D Reason:
Calculating the client's score on the Hamilton Rating Scale for Anxiety (HAM-A) is useful for assessing the severity of anxiety symptoms. The HAM-A is a clinician-rated scale that measures both psychic and somatic anxiety through 14 items. While this assessment is valuable for monitoring treatment progress and tailoring interventions, it is not the immediate priority when initiating care for a client with OCD. The primary focus should be on implementing therapeutic strategies that directly target OCD symptoms.