How antipsychotics are tested on the NCLEX-RN

Items fall under Pharmacological Therapies and Physiological Adaptation.

First-generationHaloperidol, chlorpromazineMainly positive symptomsMore EPS and tardive dyskinesiaHigher NMS riskSedation, anticholinergic effectsSecond-generationRisperidone, olanzapine, quetiapine,clozapinePositive and some negative symptomsFewer EPSWeight gain, glucose, lipidsClozapine: neutropeniavs
Two generations. All antipsychotics carry a boxed warning for increased mortality in older adults with dementia-related psychosis.

Extrapyramidal symptoms by timing

Timing is the clue to which EPS the client has.

When EPS usually appearHoursDaysWeeksMonthsYearsAcute dystoniaSpasmsAkathisiaRestlessnessParkinsonismTremor, rigidityTardive dyskinesiaOrofacial
EPS timing. Approximate; individual onset varies.
EPSFindingsNursing action
Acute dystoniaNeck twisting, eyes rolled up, tongue protrusionGive anticholinergic (benztropine) or diphenhydramine as ordered; airway
AkathisiaInner restlessness, pacing, cannot sit stillReport; may be mistaken for anxiety or agitation
Drug-induced parkinsonismShuffling gait, mask-like face, tremorReport; fall precautions
Tardive dyskinesiaLip smacking, tongue movements, grimacingAIMS screening; report early

The Abnormal Involuntary Movement Scale is a public-domain screening tool.

Neuroleptic malignant syndrome

A rare but potentially fatal reaction.

Neuroleptic malignant syndromeFeverOften very highRigidity"Lead-pipe" musclesAutonomicLabile BP,tachycardia,sweatingMental statusConfusion, stupor
NMS. Labs often show elevated CK. Stop the antipsychotic, cool the client, give fluids, and notify immediately.

Clozapine and metabolic monitoring

Laboratory monitoring is a nursing responsibility.

DrugMonitorReport
ClozapineAbsolute neutrophil count (ANC) on the required scheduleFever, sore throat, mouth sores, flu-like symptoms; chest pain or palpitations (myocarditis); seizures
Olanzapine, quetiapine, risperidoneWeight, waist circumference, glucose, lipids, BPRapid weight gain, signs of diabetes
All antipsychoticsOrthostatic BP, sedation, anticholinergic effectsDizziness, falls, urinary retention, severe constipation

Teach clients to rise slowly, use sunscreen (photosensitivity with some agents), and avoid alcohol.

NGN-style case

Distinguish NMS from other reactions.

functions Clinical judgment case — fever and rigidity

Three days after haloperidol was increased, a client has a temperature of 104°F (40°C), rigid muscles, BP swinging from 160/100 to 98/60, and confusion. What is the priority?

  1. Recognize cues: hyperthermia, rigidity, autonomic instability, altered mental status after a dose increase.
  2. Analyze: neuroleptic malignant syndrome.
  3. Hold the antipsychotic and notify the provider immediately.
  4. Begin cooling measures, maintain fluids, monitor vitals and urine output; anticipate CK and other labs.

Answer. Hold haloperidol and notify the provider immediately; this is likely NMS, an emergency.