Report confusion, severe agitation, or hallucinations, particularly in older adults.
Before you read
Test yourself first: 5 questions
Question 1 of 5
A client receiving an antipsychotic suddenly develops a stiff, twisted neck and the eyes deviate upward. Which medication does the nurse anticipate administering?
Answer: A. These findings describe acute dystonia (torticollis and oculogyric crisis), an early extrapyramidal reaction. The first-line treatment is an anticholinergic such as benztropine or the antihistamine diphenhydramine, given IM or IV for rapid relief. Propranolol is used for akathisia, lithium is a mood stabilizer, and lorazepam alone does not reverse a dystonic reaction.
Question 2 of 5
A client experiences an acute dystonic reaction with torticollis and oculogyric crisis shortly after receiving an antipsychotic. Which medication does the nurse anticipate administering?
Answer: B. Acute dystonia is an early extrapyramidal reaction (muscle spasms of the neck, eyes, and back). It is treated with an anticholinergic such as benztropine or the antihistamine diphenhydramine, which counteract the dopamine-acetylcholine imbalance.
Question 3 of 5
A client receiving haloperidol develops a sudden, painful spasm with the neck twisting to one side and the eyes deviating upward. Which intervention should the nurse anticipate?
Answer: A. This describes acute dystonia (torticollis and oculogyric crisis), an early extrapyramidal reaction. The treatment is an anticholinergic such as IM/IV benztropine or diphenhydramine, which rapidly relieves the spasm. It is uncomfortable but treatable; prompt administration is the expected intervention.
Question 4 of 5
A provider orders an IM injection of a medication for acute agitation that does not respond to verbal de-escalation. Which combination is a commonly used agent for chemical de-escalation?
Answer: A. Haloperidol combined with lorazepam (often with diphenhydramine to prevent dystonia) is a recognized regimen for acute agitation. The benzodiazepine sedates and the antipsychotic targets psychosis-driven agitation.
Question 5 of 5
Using Beers criteria principles, which medication is generally considered potentially inappropriate for an older adult because of its anticholinergic and sedating effects?
Answer: B. Diphenhydramine, a first-generation antihistamine, is flagged on the Beers criteria because its strong anticholinergic effects cause confusion, urinary retention, constipation, and falls in older adults. Acetaminophen, lisinopril, and metformin are not on that high-risk anticholinergic list.
Keep the streak going with more questions like these, each with a full rationale.
Key points to remember
- It causes pronounced drowsiness and CNS depression, so it is sedating compared with second-generation antihistamines.
- Anticholinergic effects include dry mouth, urinary retention, constipation, blurred vision, and tachycardia.
- It is on the Beers list as potentially inappropriate in older adults due to confusion and fall risk.
- It is used as an adjunct in allergic reactions and to counter extrapyramidal/dystonic reactions.
- Effects are additive with alcohol and other CNS depressants.
Signs & symptoms
- Drowsiness, dry mouth, constipation
- Urinary retention, blurred vision
Nursing priorities
- Implement fall precautions, especially in older adults, due to sedation and dizziness.
- Assess for urinary retention and constipation from anticholinergic effects.
- Caution the patient against driving or operating machinery after dosing.
- Avoid combining with alcohol or other sedatives.
Patient teaching
- This medicine makes most people sleepy; do not drive until you know how it affects you.
- Avoid alcohol while taking it.
- Increase fluids and fiber to prevent constipation and report trouble urinating.
Red flags: report now
- Report confusion, severe agitation, or hallucinations, particularly in older adults.
- Never give to patients with narrow-angle glaucoma or significant urinary retention without provider clearance.
References
Clinical references for this topic
