Neuroleptic malignant syndrome (high fever, rigidity, altered consciousness, unstable vitals) is a medical emergency requiring the drug to be stopped immediately.
Before you read
Test yourself first: 5 questions
Question 1 of 5
A nurse is teaching a client and family about the difference between typical and atypical antipsychotics. Which statement by the family member indicates correct understanding?
Answer: B. Atypical (second-generation) antipsychotics treat both positive and negative symptoms and have a lower risk of extrapyramidal symptoms than typical (first-generation) agents, but they carry a higher risk of metabolic effects such as weight gain and diabetes. Typical agents primarily target positive symptoms and cause more EPS. The statement that atypicals carry a higher metabolic risk reflects accurate understanding.
Question 2 of 5
A client started on an antipsychotic asks how to manage the orthostatic hypotension they have been feeling. What is the nurse's best teaching?
Answer: B. Antipsychotics commonly cause orthostatic (postural) hypotension. Clients should change positions slowly, rising gradually from lying to sitting to standing, and dangle their legs before standing to reduce dizziness and prevent falls.
Question 3 of 5
A client with dementia is prescribed an antipsychotic for severe, dangerous agitation. What is the most important nursing consideration?
Answer: A. Antipsychotics carry a boxed warning for increased mortality in older adults with dementia-related psychosis and are reserved for severe symptoms at the lowest effective dose for the shortest time, with ongoing monitoring. Long-term routine use for all agitation and ignoring side effects are unsafe.
Question 4 of 5
A client receiving a first-generation antipsychotic asks why he must wear sunscreen and a hat outdoors. Which is the nurse's best response?
Answer: A. First-generation antipsychotics such as chlorpromazine cause photosensitivity, increasing the risk of severe sunburn with sun exposure. Teaching includes using sunscreen, wearing protective clothing, and avoiding prolonged direct sunlight. The drug does not lower body temperature dangerously in this way, cause permanent skin darkening as the main concern, or block vitamin D synthesis; the priority teaching point is preventing photosensitivity reactions.
Question 5 of 5
A client taking a first-generation antipsychotic reports dry mouth, constipation, blurred vision, and urinary hesitancy. The nurse recognizes these as which type of effect?
Answer: A. Dry mouth, constipation, blurred vision, and urinary hesitancy are classic anticholinergic side effects of many antipsychotics. Nursing care includes offering sugarless candy or fluids, increasing fiber and fluids, and monitoring for urinary retention. These are not extrapyramidal, photosensitivity, or serotonergic effects; recognizing them as anticholinergic guides appropriate symptom management.
Keep the streak going with more questions like these, each with a full rationale.
What is antipsychotics?
Typical (first-generation) agents like haloperidol cause more extrapyramidal symptoms, while atypical (second-generation) agents like risperidone and olanzapine cause more metabolic effects. The most dangerous adverse effect is neuroleptic malignant syndrome. Memory aid: typicals cause movement problems (EPS), atypicals cause metabolic weight/sugar problems.
Key points to remember
- Extrapyramidal symptoms (EPS) include acute dystonia, akathisia (restlessness), pseudoparkinsonism, and tardive dyskinesia (often irreversible involuntary movements).
- Neuroleptic malignant syndrome (NMS) is a life-threatening reaction with high fever, severe muscle rigidity, altered mental status, and autonomic instability.
- Atypical agents commonly cause weight gain, hyperglycemia, and elevated lipids (metabolic syndrome).
- Clozapine carries a risk of agranulocytosis, requiring regular white blood cell and absolute neutrophil count monitoring.
- Anticholinergic effects (dry mouth, constipation, urinary retention, blurred vision) and orthostatic hypotension are common.
- Full therapeutic effect on psychotic symptoms may take several weeks.
Nursing priorities
- Assess for extrapyramidal symptoms and abnormal involuntary movements (such as with the AIMS scale).
- Monitor temperature, vital signs, and muscle tone for signs of neuroleptic malignant syndrome.
- Monitor weight, blood glucose, and lipids, especially with atypical agents.
- Monitor WBC and ANC for patients on clozapine and report drops promptly.
- Implement fall precautions for orthostatic hypotension and treat anticholinergic effects.
Labs & values
Patient teaching
- Rise slowly to avoid dizziness, and do not stop the medication abruptly.
- Report fever, muscle stiffness, sore throat, or abnormal movements right away.
- Use sunscreen due to photosensitivity, and attend all blood-monitoring appointments if on clozapine.
Red flags: report now
- Neuroleptic malignant syndrome (high fever, rigidity, altered consciousness, unstable vitals) is a medical emergency requiring the drug to be stopped immediately.
- Acute dystonia such as muscle spasms of the neck, jaw, or back, or oculogyric crisis.
- Signs of agranulocytosis in clozapine patients such as sore throat, fever, and infection.
- Tardive dyskinesia, which may be irreversible, requires prompt provider notification.
References
Clinical references for this topic
