Schizophrenia and Antipsychotic Adverse Effects
What it is
Schizophrenia is a chronic psychotic disorder with positive symptoms (hallucinations, delusions, disorganized speech and behavior) and negative symptoms (flat affect, poverty of speech, avolition, social withdrawal). Positive symptoms are linked to excess dopamine activity. Antipsychotics block dopamine D2 receptors, which reduces psychosis but also causes extrapyramidal symptoms (EPS). Second-generation drugs also block serotonin, so they cause fewer EPS but more weight gain, hyperglycemia and dyslipidemia.
What the NCLEX focuses on
- Hallucinations: first ask what the voices are saying, to detect command hallucinations; then acknowledge the experience without agreeing.
- Delusions: do not argue or agree; respond to the feeling and focus on reality-based topics.
- Acute dystonia (neck, jaw or eye spasm) appears within hours to days; give the prescribed benztropine or diphenhydramine and watch the airway.
- Akathisia (restlessness, pacing) and pseudoparkinsonism (shuffling gait, tremor, rigidity, masklike face) appear over days to weeks.
- Tardive dyskinesia (lip smacking, tongue thrusting) appears after months to years, is often irreversible, and is screened with the AIMS.
- Neuroleptic malignant syndrome (NMS): high fever, lead-pipe rigidity, confusion, unstable blood pressure and elevated CK; stop the antipsychotic.
- Clozapine causes severe neutropenia; check the absolute neutrophil count (ANC) regularly and report fever or sore throat at once.
Priority nursing actions
- Assess safety: command hallucinations and risk of harm to self or others.
- For fever with rigidity, stop the antipsychotic and notify the provider immediately.
- Begin cooling, IV fluids and continuous monitoring of temperature, vital signs and urine output.
- For acute dystonia, protect the airway and give the prescribed anticholinergic.
- Monitor ANC for clozapine and weight, glucose and lipids for second-generation drugs.
- Provide a calm, structured environment with brief, frequent, nondemanding contacts.
Numbers to know
| Adverse effect | Onset | Key finding and action |
|---|---|---|
| Acute dystonia | Hours to days | Muscle spasm of neck, jaw or eyes; benztropine or diphenhydramine |
| Akathisia | Days to weeks | Restlessness, cannot sit still; report for dose change |
| Pseudoparkinsonism | Days to weeks | Shuffling gait, tremor, rigidity; anticholinergic |
| Tardive dyskinesia | Months to years | Lip smacking, tongue thrusting; AIMS; report early |
| NMS | Most often early in therapy or after a dose increase | Fever, rigidity, high CK; stop the drug |
| Clozapine ANC | Hold and report below 1,000/mm3 (1.0 x 10^9/L) | Severe neutropenia and infection risk |
Common exam traps
- Choosing to tell the client the delusion is false or to agree with it: wrong because arguing builds mistrust and agreeing reinforces the delusion.
- Choosing to ask how long the voices have been present as the priority: wrong because command content determines safety.
- Choosing an antipyretic while continuing the antipsychotic for fever and rigidity: wrong because NMS requires stopping the drug immediately.
- Choosing an anticholinergic for tardive dyskinesia: wrong because anticholinergics do not treat it and can worsen it; report it.
- Choosing to treat a sore throat on clozapine as a minor cold: wrong because it signals neutropenia and infection.
What to teach
- Take the medication daily even when symptoms improve; never stop it abruptly.
- Rise slowly, use sugar-free gum or sips of water for dry mouth, and increase fiber and fluids for constipation.
- Report fever, sore throat, muscle stiffness, restlessness or involuntary movements.
- Avoid alcohol and heat exposure, use sunscreen, and keep weight and blood glucose checks.
Try 2 NCLEX-style questions on this topic
From the NCLEXPace question bank. Pick your answers, then check them inside NCLEXPace.
A client with schizophrenia states, "The government has planted a device in my apartment to record everything I say." For each nurse response, indicate whether it is therapeutic or nontherapeutic.
For each nurse response to a client's persecutory delusion, indicate whether it is therapeutic or nontherapeutic.
| Therapeutic | Nontherapeutic | |
|---|---|---|
| "Let's not talk about this and focus on something else." | ||
| "Yes, I have heard that they are watching a lot of people." | ||
| "There is no device; the government is not doing this." | ||
| "That sounds frightening. Tell me about today." |
A client taking an antipsychotic medication develops a fever of 40.1 C (104.2 F), rigid muscles throughout the body, confusion, and a heart rate of 128 with an unstable blood pressure. Which action should the nurse take first?
Select the best answer.
- A. Stop the antipsychotic and notify the provider immediately
- B. Apply a cooling blanket, begin intravenous fluids, and continue the antipsychotic at the scheduled dose while treating the hyperthermia
- C. Administer the prescribed antipyretic, provide oral or IV fluids, and repeat the temperature and neurologic assessment in 4 hours
- D. Increase the antipsychotic dose because the confusion and agitation may represent worsening psychosis that is contributing to the autonomic instability
The correct answers, the reasoning for every option and 3,200+ more NCLEX questions are inside NCLEXPace. Create your account, then choose a plan to open them.
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- Keepers GA, Fochtmann LJ, Anzia JM, et al. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia. Am J Psychiatry. 2020;177(9):868-872.
- Halter MJ. Varcarolis' Foundations of Psychiatric-Mental Health Nursing: A Clinical Approach. 9th ed. Elsevier; 2022.
- Clozapine tablets. Prescribing information. DailyMed, US National Library of Medicine.
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