In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of behavioral interventions in order to:

  • Assess the client's appearance, mood and psychomotor behavior and identify/respond to inappropriate/ abnormal behavior
  • Assist the client with achieving and maintaining self-control of behavior (e.g., contract, behavior modification)
  • Assist the client to develop and use strategies to decrease anxiety
  • Orient the client to reality
  • Participate in group sessions (e.g., support groups)
  • Incorporate behavioral management techniques when caring for a client (e.g., positive reinforcement, setting limits)
  • Evaluate the client's response to treatment plan

Assessing the Client's Appearance, Mood and Psychomotor Behavior and Identifying and Responding to Inappropriate and Abnormal Behavior

Assessing the Client's Appearance, Mood and Psychomotor Behavior

The client's appearance, mood, psychomotor behaviors and changes of these and other client characteristics provide nurses with the elements of an in depth client assessment in terms of their current psychological status and the presence of possible adverse behaviors that have to be managed before their occur. Reactive behavioral management is far less effective than proactive behavior management that prevents poor patient behaviors.

The patient's appearance is monitored in respect to the person's posture, gait, hygiene, grooming, and other things like the appropriateness of their attire. Under normal circumstances, the client should be well groomed, normally postured, and dressed in clothing that is appropriate for the environment and the setting. For example, a lady who walks into the community health care setting during the winter months wearing nothing other than a body revealing night gown is indicating that her choices are not appropriate for the weather and also not appropriate while in a health care setting that is open to the public.

The patient's mood and affect are monitored by interpreting their verbal and nonverbal communication. For example, is the patient's mood happy, elated, somber, sad, depressed or flat and without any emotion whatsoever? Is the patient making eye contact, making any facial grimaces or unusual sounds and/or having any unusual psychomotor bodily movements that can indicate the patient's mood? For example, pacing may indicate agitation, anger, hostility and/or restlessness.

Other psychological data that are collected include data and information about the client's level of consciousness and the client's level of cognition. Some of this data is collected during the client interview and using some standardized tests and tools.

The client's level of consciousness is assessed and then described as one of the six levels of consciousness which are, in descending order from the highest level of consciousness to the lowest level of consciousness are:

  • Alert
  • Confused
  • Lethargic
  • Obtunded
  • Stuporous
  • Comatose

Alert patients follow commands and answer questions appropriately; confusion is evident when the patient is in need of cues in order to respond to commands and questions, when the patient is not oriented to their environment, and/or when the patient lacks good judgment and good thinking processes; lethargic clients are sleepy but they can be awakened with verbal or tactile stimuli; obtunded patients respond to stimulation but very slowly and only with repeated stimulation; stuporous clients respond to vigorous stimulation with merely basic responses like a grunt or a groan; and, finally, the lowest level of consciousness, which is coma, is characterized with the complete unresponsiveness to all stimuli, painful and not painful.

Levels of consciousness can also be categorized as a persistent vegetative state, locked in syndrome and brain death.

A persistent vegetative state is characterized with no cognitive functioning and the retention of only basic human functions like eye opening.

Brain death occurs when the coma is irreversible, the patient is completely unresponsive to all stimuli, and the patient has a total loss of all respiratory function as well as all the total loss of all brainstem reflexes and functioning.

Patients with locked in syndrome have some retained cognitive function but they lack all motor functioning. In this state, the client is able to communicate with eye movements and they are typically aware of their surroundings.

Levels of consciousness can also be determined and measured using the standardized Glasgow Coma Scale for adults and children or the Rancho Los Amigos Scale. The pediatric and adult Glasgow Coma Scales measure the patient's motor responses, verbal responses and eye opening. The Rancho Los Amigos Scale determines the patient's level of awareness and functioning which can range from a 1 to an 8 when a 1 is the complete lack of all responsiveness to all stimulation and an 8 is when a patient is fully alert, oriented, appropriate and purposeful.

The client's level of cognition is assessed by determining the client's orientation to time, or day, person and place, the client's grounding in reality, the client's remote or long term memory, the client's intermediate or recent memory and the client's short term or immediate memory, the client's accuracy in terms of their understanding and insight into one's illness, the rate and quality of the client's spoken words, and the client's ability to abstract.

The Mini Mental State test is a standardized test tool that is often used to assess the client's level of cognition. The Mini Mental State test assesses the client's current status in terms of orientation, simple mathematical calculations, their ability to recognize and identify common objects, their command of their language and their ability to respond to and follow the commands of others.

These psychological assessments are modified for children and adolescents as well as clients in the older population.

Some of the modifications for children and adolescents include an assessment of the child's:

  • Level of growth and development
  • Ability to meet developmental challenges
  • Temperament
  • View of their world as one that is trusting and secure
  • Coping mechanisms
  • Mood including things like an eating disorder and suicidal risk

Some of the modifications for the elderly population include an assessment of the client using special standardized tests such as the:

  • Geriatric version of the Michigan Alcoholism Screening Test
  • Geriatric Depression Scale
  • Pain Assessment in Advanced Dementia Scale
  • The FACES and the McGill Pain Assessment for pain

Identifying and Responding to Inappropriate and Abnormal Behavior

Inappropriate and abnormal behaviors can potentially affect clients of all ages. For example, the elderly client may be exhibiting physical or verbal aggression and anger as the result of dementia; the adult client may be impulsive, suicidal and even homicidal as the result of depression secondary to the loss of a job; the adolescent may be suicidal as the result of some disfiguring deformity; a school age child may bully others in school as the result of some underlying psychological disorder such as poor self-esteem; a preschool child may become socially withdrawn as the result of child abuse or neglect; a toddler may become defiant as the result of a developmental milestone such as toilet training; and an infant may be listless as the result of a lack of parental bonding or the lack of the development of trust.

Some of the risk factors, other than those just mentioned above, associated with inappropriate and problem behaviors, which can include dangerous behaviors, are living in a violent and dysfunctional family and/or environment, a past history of inappropriate behavior, limited or absent social support systems, poor coping strategies, poor impulse control, poor self-control, and psychiatric disorders that are accompanied with hallucinations or delusions.

During the assessment of the client, the nurse will collect and analyze data that not only includes the client's behaviors, but also any triggers that may have precipitated the behavior and the nature of the behavior in terms of whether or not it is disruptive or dangerous to the client and/or others. An example of an inappropriate behavior that is disruptive is a client's yelling out and invading the personal space of another client; and examples of inappropriate behaviors that are dangerous to self or others are a client's clenching their fist in the face of a staff member or another client and punching a staff member or visitor.

As nurses assess the causes of inappropriate and dangerous behavior, they consider environmental, physical, psychological and social factors that may trigger and provoke these behaviors among their clients.

Some of the environmental forces and factors that can precipitate inappropriate and dangerous patient behaviors can include hot or cold ambient temperatures, noxious odors, noises, and lights; physical forces and factors that can precipitate inappropriate and dangerous patient behaviors can include physical illness, pain, fever, fatigue, and sensory or perceptual disorders such as impaired sight and hearing; some of the psychological forces and factors that can precipitate inappropriate and dangerous patient behaviors can include the presence of an existing psychiatric mental disorder, delusions, delirium, psychological trauma and crisis, and neglect and abuse.

Additional assessments into the causes of inappropriate and dangerous behavior include the determination of events and situations that were present just prior to the behaviors, where the behaviors occurred, when and what time of day the behaviors occurred, and what environmental factors may have contributed to the triggering of the event.

Assisting the Client with Achieving the Self-Control of Behavior

One of the single most important things to prevent inappropriate and dangerous behaviors is to prevent these episodes from occurring. Some of these preventive measures include the provision of a safe, supportive and consistent environment and the identification of and the elimination of potential triggers to the inappropriate and dangerous behaviors.

Other preventive measures specific to the client's needs can include:

  • Encouraging stress and relaxation techniques
  • Maintaining a consistent environment, consistent schedules and routines including a routine and consistent bed time
  • Physical exercise
  • Other alternative and complementary strategies including pet and music therapy
  • The promotion of appropriate socialization and leisure time activities

When these preventive measures are not successful, multidisciplinary interventions to stop the violent and dangerous behavior can include:

  • Timely and rapid de-escalation
  • Providing the client with clear and concise ways to cease the behavior in a calm voice and demeanor
  • Maintaining eye contact with the client and at the same level as the client
  • Providing positive reinforcements when the client makes efforts to control their own behavior
  • Setting and adhering to limits for the client
  • Engaging the client in some form of physical activity, like walking, to diffuse the client's anxiety, anger and hostility
  • Medications such as haloperidol, ziprasidone and olanzapine
  • Seclusion or restraint as a last resort when all other measures have failed and the client remains an imminent risk of serious harm to self and/or others

Poor behaviors are best prevented within an environment that is without stressors and triggers that precipitate poor behavior. Milieu therapy, as well as the establishment and maintenance of a therapeutic relationship, can eliminate as many stressors and triggers from the environment as possible.

Milieu therapy entails the planned and systematic changing of the patient's environment so that the patient has the opportunity to better cope and adapt when all extraneous variables in the environment are eliminated. When these factors are consistently eliminated, the patient is better able to identify and stay in keeping with established boundaries and rules, they are better able to avoid stressful stimuli and triggers, and they are better able to participate in appropriate activities and communication.

Nurses also employ a number of strategies and interventions to facilitate the client's own self control of behavior with setting and maintaining clear limits, setting realistic goals and expectations with the client, providing the client with praise, rewards and other positive reinforcements for client progress, modeling, desensitization, behavior modification, contracting, operant conditioning, and aversion therapy, among other strategies.

Modeling gives the client the opportunity to observe, mimic and practice appropriate behaviors that are most often provided by the psychological therapist.

Desensitization is the well planned, purposeful, progressive and systematic exposure of the client to progressively more provocative and intense stimuli so that the patient can learn how to cope with these stimuli in a progressive manner with the support and encouragement of those involved in the care of the patient.

Behavior modification is a planned and systematic intervention that aims to change the patient's behaviors with the consistent reinforcement of positive and adaptive behaviors with praise and rewards, and the consistent use of negative reinforcement for negative maladaptive behaviors, such as acting out.

Contracting entails a formal written and signed contract that details what the patient can and cannot do.

Operant conditioning, like Skinner's theory, is the provision of positive reinforcement and rewards for appropriate behaviors.

Lastly, aversion therapy is the use of negative reinforcements, such as the cessation of privileges, when the client demonstrates inappropriate or dangerous behaviors.

All episodes of inappropriate and dangerous behaviors are followed up and discussed with a client follow up that includes a discussion about ways that the client can gain and maintain better self-control in the future, a staff debriefing about the incident, ways to prevent it in the future, the effectiveness of the provided interventions, and complete documentation that includes what triggered the behavior, what happened during the episode, when it happened, where it happened, how long the behavior lasted and what was done to stop the inappropriate and dangerous behavior.

Caregivers, families and friends often provide a support system for the client when it comes to coping with and adapting to psychological disorders such as those requiring behavior management. These supports should encourage the patient to use positive behaviors, they should provide the patient with support and compassion, and they should educate the client so that the client will know how to prevent and deescalate inappropriate behaviors.

Nurses, therefore, should instruct and reinforce teaching for patients and their caregivers about all of these issues and the known triggers that precipitate the inappropriate behaviors for the patient including environmental, physical and psychological triggers.

Assisting the Client In Using Behavioral Strategies To Decrease Anxiety

According to the National North American Nursing Diagnosis Association International, anxiety is defined as " A vague, uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual), a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and it enables the individual to takes measures to deal with the threat."

The defining characteristics, signs and symptoms of anxiety include physiological ones including trembling, a quivering voice and tremors, behavioral changes such as fidgeting, insomnia, restlessness, hyper vigilance and poor eye contact; affective signs and symptoms such as irritability, feelings of helplessness, feeling jittery, and fright can also occur; parasympathetic nervous system responses such as decreased pulse, diarrhea, faintness and decreased blood pressure occur; sympathetic nervous system responses such as increased blood pressure, increased cardiac rate, pupil dilation, hyperpnea, and anorexia can result from anxiety, and lastly, cognitive characteristics, signs and symptoms like confusion, a poor ability to concentrate, poor problem solving, forgetfulness, a diminished attention span, impairments in the ability to learn, and intense fear can also occur when the client is adversely affected with anxiety.

The registered nurse assesses the client for subjective and objective signs and symptoms of anxiety and then arrives at nursing diagnoses and an appropriate plan of care as based on this assessment. The standardized Face Anxiety Scale can be used to assess the presence and intensity of the client's anxiety. For example, when the source of the anxiety is identified, the nurse will encourage the client to understand that the anxiety is rational as a response to some stressor or crisis, after which treatment strategies, such as those below, will be rendered.

Behavioral strategies to decrease anxiety include cognitive reframing and a wide variety of stress management relaxation techniques like those that we will discuss now.

  • Cognitive reframing is done to teach the patient to stop negative thoughts by consciously replacing these negative thoughts and impulses with positive thoughts.
  • Deep breathing consists of taking deep and cleansing breaths using the diaphragm. The procedure for deep breathing entails taking as deep a breath as possible, holding it, and then slowly exhaling while thinking peaceful thoughts.
  • Progressive relaxation involves contracting and releasing all muscle groups in the body. Most people begin with their feet and then they work their way upward in an orderly and systematic manner. The procedure for progressive relaxation involves contracting and creating tension in the muscle groups and then relaxing and releasing the muscular contractions.
  • Meditation is deep focus and thought. Meditation is often difficult for beginners because they are not used to sitting quietly with nothing other than one's own thoughts. But, with practice, most people can master this deep focus and thought. Meditation can be done anywhere and at any time provided that the person is not easily distracted. Many cultures and religions use meditation for spiritual and religious purposes.
  • Prayer is a formalized form of religious meditation. Like meditation, prayer requires deep focus and thought.
  • Reminiscence therapy is the sharing of life stories, memories, personal biographies and histories with others. Reminiscence therapy gives the person who is sharing their story an opportunity to not only relate historical facts but also to share how they felt about and coped with the stressful events during their life. Reminiscence therapy gives the person a feeling of self-esteem and value.
  • Validation therapy is beneficial to patients because it allows the patient to resolve conflicts and issues as the therapist recognizes and empathizes with the patient's experiences and responses as conflicts and issues are resolved.
  • Journaling provides the opportunity for people to record and document their feelings and thoughts. At times, people will incorporate events or interactions that trigger their feelings and thoughts so that, at a later date, the person can look back over their journaling entries to identify and patterns or trends. For example, the person may notice that their stress and anxiety increases when they are tired or when they are interacting with a particular person.
  • Guided imagery is quite similar to meditation. In fact, guided imagery is often used with meditation. Guided imagery involves the person's visualization of a peaceful scene like a sunset or a quiet beach with rolling waves while they think peaceful thoughts.
  • Music therapy can be used alone or in combination with other anxiety reducing techniques such as deep breathing, meditation, and guided imagery.
  • Biofeedback is not done as often as other stress management and anxiety reducing techniques. Biofeedback involves the patient's being hooked up to externally placed electrodes and then connected to a visual display of the patient's heart rate, pulse rate, body temperature, breathing, etc. when exposed to stressors. The patient then performs some relaxation techniques, such as deep breathing, as they watch their internal bodily control over these bodily responses to stress.
  • Mindfulness entails becoming acutely aware of the environment and the person's immediate surroundings to gain insight into it as anxiety is reduced.
  • Resetting priorities allows the person to think about and renumber their priorities so that things can be manageable and put into perspective.
  • Positive self talk
  • Medications

Orienting the Client to Reality

Reality orientation is defined as "a program designed to improve cognitive and psychomotor function in persons who are confused or disoriented. It is often employed in long-term facilities to create an environment in which perceptions of the environment in relation to the external world are directed toward the reality of that world. Aids such as calendars and clocks and sensory stimuli such as distinctive sights, sounds, and smells are used to improve sensory awareness. The expected outcome of such programs for severely impaired persons is improvement in intellect and language skills, and increased participation in the activities of daily living". (Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. 2003)

Reality orientation is the promotion of client's cognizance of their personal identity, time, and the environment that is surrounding the client. It utilizes specific approaches that assist confused or disoriented clients towards an awareness of reality by emphasizing things such as the time, day, month, year, circumstance and weather. Helpful aids include calendars, frequent orientation reminders and clocks.

Participating in Group Sessions

Nurses not only participate in and lead group therapy sessions but they also encourage their patients to participate in them. Group sessions facilitate the participants' sharing their feelings, fears, concerns, and experiences with others. These things give patients the opportunity to ventilate and it also gives the participants an opportunity to provide feedback to the person who is doing the sharing.

Examples of group therapy include psychosocial support groups, groups specifically for different age groups like children, teenagers, young adults, adults and geriatric clients depending on the specific needs of these age groups, stress management groups, substance related abuse groups, understanding mental illness groups, and physical health and peer support groups like those for cancer or diabetes.

Some groups are open to new members as members leave the group and other groups are closed to new members; some groups are heterogeneous which include members of both genders and with all psychiatric mental health disorders, for example, and others, such as female or male only groups and groups with members who share the same psychiatric mental health disorder, are homogeneous groups.

Some of the characteristics of groups, in addition to their membership, include group leadership, norms, group growth and development, level of cohesion and subgroup formation. More about groups and group process will be detailed later in this NCLEX-RN review.

Incorporating Behavioral Management Techniques When Caring for a Client

As previously detailed above under "Assisting the Client with Achieving the Self-Control of Behavior", nurses employ a number of strategies and interventions to facilitate the client's own self control of behavior with setting and maintaining clear limits, setting realistic goals and expectations with the client, and providing the client with praise, rewards and other positive reinforcements for client progress. Modeling, desensitization, behavior modification, contracting, operant conditioning, and aversion therapy, among other strategies are used for behavior management.

Evaluating the Client's Responses to The Treatment Plan

As with the evaluation of all nursing care and patient responses, patient responses to behavioral management interventions are compared to the pre-established expected outcomes to determine whether or not these interventions were successful in meeting these expected outcomes.

Expected outcomes for inappropriate and dangerous behaviors can include:

  • The client will participate in group therapy sessions
  • The client will identify their triggers
  • The client will avoid their triggers
  • The client will adhere to their limits
  • The client will demonstrate appropriate behaviors
  • The family will effectively cope with and manage the client's inappropriate and/or dangerous behaviors

Some expected outcomes for clients with anxiety can include:

  • The client will participate in group therapy sessions
  • The client will express a decrease in their level of anxiety
  • The client will not demonstrate any cognitive, physiological, behavioral, affective, parasympathetic nervous system, or sympathetic nervous system alterations related to anxiety
  • The client will be able to perform their activities of daily living
  • The client will effectively utilize traditional and complementary techniques to decrease their anxiety


SEE – Psychosocial Integrity Practice Test Questions

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