Psych / Mental Health · Psychotic Disorders
Schizophrenia & Psychosis
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Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current references.
If you or someone you know is in crisis: call or text 988 (Suicide & Crisis Lifeline, U.S.) or call 911 for immediate danger. This guide is for exam study, not for diagnosing or treating anyone.
1. Overview
Psychosis is a loss of contact with reality — , , or severely disorganized thinking. Schizophrenia is a chronic psychotic disorder (symptoms ≥ 6 months, with active-phase symptoms) that usually starts in late teens to early 30s. The dopamine hypothesis: excess dopamine in some brain pathways → positive symptoms; too little in others → negative/cognitive symptoms. Glutamate and genetics also play roles; cannabis use and stress can trigger onset in vulnerable people.
Related: schizoaffective disorder (psychosis + major mood episodes), brief psychotic disorder, delusional disorder, substance- or medically-induced psychosis (always rule out delirium, intoxication, steroids, infection).
2. Signs & Symptoms
| Positive (added — respond better to meds) | Negative (lost — harder to treat) |
|---|---|
| Hallucinations (auditory most common) | Alogia (poverty of speech) |
| Delusions (persecutory, grandiose, ) | Avolition (no motivation) |
| Disorganized speech: , word salad, , clang associations, | Anhedonia, asociality |
| Disorganized or catatonic behavior | Flat/blunted affect |
Memory aid for negatives — the 5 A’s: Alogia, Avolition, Anhedonia, Affect flat, Attention/Asociality.
3. Priority Nursing Actions
- Safety: ask about command hallucinations — “Are the voices telling you to hurt yourself or anyone else?” Command hallucinations to harm = highest priority
- Hallucinations: acknowledge the experience without confirming it — “I don’t hear the voices, but I understand they’re real to you. What are they saying?” Focus on reality, reduce stimuli, engage in concrete activities
- Delusions: don’t argue or agree; don’t reinforce. Focus on feelings (“That must be frightening”) and on reality-based topics. For paranoia, offer sealed/packaged food and let the patient see meds come from sealed packages
- Build trust with short, frequent, consistent contacts; honest, simple, concrete language (avoid jokes/abstract phrases)
- Agitation: first — calm voice, space, offer choices, reduce stimuli, PRN oral meds; restraint/seclusion only as a last resort, per order and policy, with frequent monitoring
- Self-care support, social skills training, family psychoeducation, medication adherence (long-acting injectables can help)
4. Antipsychotic Medications
| First-generation (“typical”) | Second-generation (“atypical”) | |
|---|---|---|
| Examples | Haloperidol, chlorpromazine, fluphenazine | Risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone, lurasidone, clozapine |
| Main concern | (high), NMS | (weight, glucose, lipids), some EPS (risperidone), (ziprasidone) |
| Negative symptoms | Little effect | Some benefit |
Extrapyramidal symptoms (onset order):
| EPS | Looks like | Treatment |
|---|---|---|
| (hours–days) | Neck/eye/tongue spasm, oculogyric crisis, laryngospasm | IM/IV diphenhydramine or benztropine; airway |
| Pseudoparkinsonism (days–weeks) | Shuffling gait, tremor, rigidity, mask face | Benztropine, dose change |
| (days–weeks) | Restless, pacing, can’t sit still | Propranolol, dose reduction; don’t mistake for anxiety |
| (months–years) | Lip smacking, tongue thrusting, grimacing | AIMS screening; VMAT2 inhibitors (valbenazine, deutetrabenazine); may be permanent |
Clozapine (treatment-resistant schizophrenia, reduces suicide risk): → regular ANC monitoring; report fever/sore throat; also seizures, myocarditis, severe constipation, sialorrhea, orthostasis, metabolic effects.
Metabolic monitoring for SGAs: baseline and periodic weight/BMI, waist, BP, fasting glucose/A1C, lipids.
5. Emergency: Neuroleptic Malignant Syndrome
— rare but potentially fatal; usually within the first weeks or after a dose increase.
- Signs: hyperthermia, “lead-pipe” rigidity, altered mental status, autonomic instability (BP swings, tachycardia, diaphoresis), elevated CK, possible myoglobinuria/AKI
- Actions: stop the antipsychotic, notify provider, cooling, IV fluids, monitor kidney function; meds such as dantrolene or bromocriptine per provider; ICU care
- Compare: serotonin syndrome = rapid onset, clonus/hyperreflexia; NMS = slower onset, rigidity/bradyreflexia
6. Patient & Family Education
- Take meds consistently; relapse is common when stopped. Report fever, stiffness, sore throat, abnormal movements
- Rise slowly (orthostatic hypotension); stay hydrated; avoid overheating (impaired heat regulation)
- Healthy diet and activity to counter weight gain; avoid alcohol and cannabis
- Relapse warning signs: sleep changes, withdrawal, suspiciousness
7. Memory Aids
- NMS = “FEVER”: Fever, Encephalopathy, Vital sign instability, Elevated CK, Rigidity
- EPS timeline “Dystonia Hours, Akathisia Days, Parkinsonism Weeks, Tardive Years”
- Clozapine — “C for Counts” (ANC)
8. NCLEX-Style Practice Questions
1. A patient says, “The voices are telling me to hurt my roommate.” What is the nurse’s priority?
A. Explain that the voices are not real
B. Ensure the safety of the patient and the roommate
C. Encourage the patient to attend group therapy
D. Document the hallucination at the end of the shift
Answer: B. Command hallucinations to harm others are a safety emergency.
2. A patient insists the hospital food is poisoned. Which response is best?
A. “The food here is perfectly safe; I promise.”
B. “Who do you think is poisoning you?”
C. “It sounds frightening to feel unsafe. Would you like a sealed meal?”
D. “If you don’t eat, you’ll get a feeding tube.”
Answer: C. Acknowledge feelings without arguing and offer a reasonable option.
3. Two days after starting haloperidol, a patient’s neck twists sharply and the eyes roll upward. What does the nurse anticipate giving?
A. Benztropine or diphenhydramine IM
B. Lorazepam PO
C. Another dose of haloperidol
D. Dantrolene IV
Answer: A. This is acute dystonia (oculogyric crisis); an anticholinergic acts rapidly. Watch the airway.
4. A patient on fluphenazine has a temperature of 104 °F (40 °C), rigid muscles, confusion, and fluctuating BP. The priority action is:
A. Give acetaminophen and recheck in 1 hour
B. Hold the antipsychotic and notify the provider immediately
C. Give the next dose to reduce agitation
D. Encourage oral fluids and ambulation
Answer: B. These findings suggest NMS, a medical emergency.
5. A patient on clozapine reports a sore throat and fever. What should the nurse check?
A. Lithium level
B. Absolute neutrophil count
C. Serum sodium
D. Thyroid function
Answer: B. Infection signs may indicate agranulocytosis.
References
Hany, M., & Rizvi, A. (2024). Schizophrenia. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539864/
Simon, L. V., Hashmi, M. F., & Callahan, A. L. (2023). Neuroleptic malignant syndrome. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482282/
National Institute of Mental Health. (n.d.). Schizophrenia. Retrieved October 15, 2026, from https://www.nimh.nih.gov/health/topics/schizophrenia
National Council of State Boards of Nursing. (2026). 2026 NCLEX-RN test plan. https://www.nclex.com/test-plans.page