Pharmacology · chapter 13 · Psychopharmacologic Drugs
Antipsychotics
The 14 things this section of the textbook says that you are most likely to be asked about — quoted word for word, not retold. Then 6 practice questions with the reasoning.
Key points
Positive and negative symptoms
Symptoms of schizophrenia are classified as either positive, referring to an excess of distortion of normal function (e.g., hallucinations), or negative, meaning diminishing or absent behaviors related to motivation or expression (Correll Schooler, 2020).
Typical versus atypical agents
Historically, first-generation or “typical” antipsychotic agents were more effective in managing the positive symptoms versus the negative symptoms; however, the newer second-generation “atypical” medications have shown effectiveness in treating both the positive and negative symptoms.
Full effect takes months
Most of these drugs take 1–2 months to reach full therapeutic effects.
Older adults with dementia
Antipsychotics are included on the list because they are linked to higher rates of cognitive decline and death in persons with dementia.
Long-term therapy and relapse
Clients should be made aware they will usually need to remain on these drugs for years, if not for life, because there is a high rate of relapse when drug therapy is stopped.
Anticholinergic adverse effects
Most of the ADRs are related to these drugs’ anticholinergic properties, including blurred vision, dry mouth, constipation, urine retention, nasal congestion, and photophobia.
QTc prolongation and arrhythmias
Arrhythmias can be caused by the dopamine-blocking effects or prolongation of the QTc interval, which could lead to fatal arrhythmias.
Signs of neuroleptic malignant syndrome
The clinical manifestations include a sudden high-grade fever, fluctuations in blood pressure, dysrhythmias, extreme muscle rigidity, and significant tachycardia.
Lower seizure threshold
Furthermore, those with a seizure disorder may need an increase in their antiseizure medications because the antipsychotics tend to lower the seizure threshold.
Metabolic effects of atypicals
Metabolic effects are more common with these medications and include hyperglycemia and weight gain.
Baseline tests before starting
Obtain baseline physical assessment and relevant tests including an electrocardiogram, CBC, electrolytes, liver and renal function tests, lipid panel, blood glucose levels, and thyroid function.
Clozapine constipation can be serious
The constipation caused by clozapine is significant and can progress to intestinal ischemia and necrotizing colitis.
Never stop clozapine abruptly
Ensure clozapine does not get stopped abruptly because it will cause acute psychosis. This drug should be tapered over a 2-week period.
Report signs of infection
Notify the health care provider if sore throat, fever, or flu-like symptoms arise.
Terms to know
- Schizophrenia
- Schizophrenia is a severe mental disorder characterized by disorganized thought processes, blunted or inappropriate emotional responses, and bizarre behavior.
- Psychosis
- Psychosis is a collection of symptoms that include some level of disconnection with reality.
- Extrapyramidal symptoms
- First-generation antipsychotics are known to cause extrapyramidal symptoms (EPS), which are involuntary, uncontrollable movements.
- Neuroleptic malignant syndrome
- Neuroleptic malignant syndrome (NMS) is a rare but potentially fatal condition that can develop with antipsychotic use.
Practice questions
Stuck on select-all-that-apply? How to take them one option at a time.
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Every question here, with the answer
A client who started haloperidol two days ago suddenly develops a high fever, extreme muscle rigidity, fluctuating blood pressure and a fast heart rate. Which condition should the nurse suspect?
- Neuroleptic malignant syndrome
- Akathisia
- Expected anticholinergic effects
- Tardive dyskinesia
Answer: Neuroleptic malignant syndrome
Sudden high fever, blood pressure fluctuations, extreme rigidity and significant tachycardia are the manifestations of neuroleptic malignant syndrome, a rare but potentially fatal reaction that needs immediate supportive management. Tardive dyskinesia and akathisia are movement effects without fever, and anticholinergic effects do not cause this picture.
A client taking clozapine tells the nurse she has not had a bowel movement in several days and her abdomen feels full. What is the nurse's priority concern?
- The constipation can progress to intestinal ischemia and necrotizing colitis.
- Constipation is harmless and expected with clozapine.
- Constipation shows the dose is too low.
- The client should stop clozapine today.
Answer: The constipation can progress to intestinal ischemia and necrotizing colitis.
Constipation caused by clozapine is significant and can progress to intestinal ischemia and necrotizing colitis, so the client should notify the provider immediately. It is not harmless, it does not indicate a low dose, and clozapine must never be stopped abruptly.
A client on clozapine asks whether he can just stop taking it because he feels better. What should the nurse explain?
- He should skip every other dose for a week before stopping.
- He can stop it any time once symptoms improve.
- Stopping suddenly only causes mild nausea.
- Stopping it abruptly will cause acute psychosis; it must be tapered.
Answer: Stopping it abruptly will cause acute psychosis; it must be tapered.
Clozapine must not be stopped abruptly because it will cause acute psychosis; it is tapered over about two weeks. Stopping at will, skipping doses on his own, or treating withdrawal as minor are all unsafe.
A nurse is preparing a client to start an antipsychotic. Which baseline tests should the nurse obtain? Select all that apply.
- Lipid panel
- Electrocardiogram
- Complete blood count
- Pulmonary function tests
- Blood glucose level
Answer: Lipid panel, Electrocardiogram, Complete blood count, Blood glucose level
The baseline assessment includes an electrocardiogram, CBC, electrolytes, liver and renal function tests, lipid panel, blood glucose and thyroid function, reflecting risks such as QTc prolongation, blood disorders and metabolic effects. Pulmonary function tests are not part of the listed baseline.
The nurse is teaching a client who is going home on an antipsychotic. Which instructions are correct? Select all that apply.
- Wear protective clothing when out in the sun.
- Drive only if you feel drowsy in the evening.
- Stop the medication once hallucinations go away.
- Report sore throat, fever or flu-like symptoms.
- Change positions slowly.
Answer: Wear protective clothing when out in the sun., Report sore throat, fever or flu-like symptoms., Change positions slowly.
Clients should avoid quick position changes because of orthostatic hypotension, wear protective clothing in the sun, and report sore throat, fever or flu-like symptoms. They should not drive because of dizziness and sedation, and stopping the drug carries a high rate of relapse.
A client who started an antipsychotic one week ago says, "This isn't working, I still hear voices." Which response by the nurse is accurate?
- You should double the dose tonight.
- Voices mean you are allergic to the drug.
- If it has not worked in a week, it will never work.
- Most of these drugs take 1 to 2 months to reach full effect.
Answer: Most of these drugs take 1 to 2 months to reach full effect.
Most antipsychotics take 1 to 2 months to reach full therapeutic effect, and clients should understand that effects will not occur immediately. Judging failure after one week, self-adjusting the dose, or calling persisting symptoms an allergy are not supported.
Where every quote comes from
Section 13.2 Antipsychotics of Pharmacology for Nurses by Tina Barbour-Taylor, Leah Mueller (Sabato), Donna Paris, Dorie Weaver, OpenStax, 2024. Read the whole section free at openstax.org.
The textbook is licensed under CC BY-NC-SA 4.0. This page quotes it word for word and adds the headings, the order and the practice questions; references to the book's figures and stray spaces left by its formatting are removed. The page is shared under the same licence. Nothing here is sold.