A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour. The nurse should document which of the following de- escalation techniques in the client's medical record?

A. Cognitive behavioral therapy (CBT) is a commonly used psychotherapy approach for bipolar disorder. Attending a CBT class typically does not require specific informed consent beyond the general consent for treatment, as it involves non-invasive, non-experimental therapeutic techniques aimed at improving coping skills and managing symptoms. In most cases, attending therapy sessions like CBT is considered part of routine care for mental health conditions.
B. Experimental medications involve drugs or treatments that are not yet approved by regulatory agencies (such as the FDA in the United States) for general use. For a client to participate in a clinical trial or receive an experimental medication, they must provide explicit informed consent after being informed about the potential risks, benefits, and uncertainties associated with the treatment. This process ensures that the client understands they are participating in research and not receiving standard care.
C. Participating in a group exercise program is generally considered a routine therapeutic intervention aimed at promoting physical health and well-being. While informed consent is important for all interventions, including exercise programs, it typically involves providing general information about the program's goals, activities, and any potential risks. Clients are not consenting to experimental treatments or procedures that go beyond standard exercise protocols.

D. Light therapy, also known as phototherapy, is a treatment often used for seasonal affective disorder (SAD) and other mood disorders. It involves exposure to specific wavelengths of light to regulate circadian rhythms and improve mood. While light therapy is a specialized treatment, it is a standard intervention for mood disorders and does not typically require separate informed consent beyond what is provided for standard medical treatments.

A. While medications like SSRIs (Selective Serotonin Reuptake Inhibitors) or benzodiazepines may eventually be part of the treatment plan for OCD, administering medication should not be the first action unless the client is in acute distress or experiencing severe anxiety symptoms that require immediate pharmacological intervention.
B. This option involves assessing the severity of anxiety symptoms, which is important for understanding the client's baseline anxiety level. However, calculating this score is not the first action. It can be done later as part of the comprehensive assessment to guide ongoing treatment planning.
C. Relaxation exercises, such as deep breathing or progressive muscle relaxation, can help manage anxiety symptoms in clients with OCD. However, before initiating specific interventions like relaxation exercises, the nurse should first establish rapport, assess the client's current level of distress, and gather information about the client's symptoms and coping mechanisms.
D. Response prevention is a cognitive-behavioral therapy technique used in the treatment of OCD, where clients are prevented from engaging in compulsive behaviors. This should follow after thorough assessment of the actual psychological state of the client.