Antipsychotic medications remain essential in treating schizophrenia, bipolar disorder, acute psychosis, and severe agitation. For NCLEX success and safe practice, every registered nurse must understand how first-generation and second-generation antipsychotics differ in action, side effects, and nursing responsibilities.

This simple guide helps RN nurses, nursing students, and anyone using a nursing bundle strengthen their understanding of these medications.

What Are Antipsychotics? (Simple Definition)

Antipsychotics are medications that help manage hallucinations, delusions, agitation, and thought disorders.
They work mainly by altering dopamine and serotonin activity in the brain.

There are two major groups:

First-Generation (Typical) Antipsychotics
Second-Generation (Atypical) Antipsychotics

Both classes appear on the NCLEX frequently, so nurses must understand their differences clearly.

First-Generation Antipsychotics (Typical)

These medications primarily block dopamine (D2) receptors and are very effective for positive symptoms of schizophrenia (hallucinations, delusions, agitation).

Common First-Gen Drugs

Haloperidol (Haldol)
Chlorpromazine (Thorazine)
Fluphenazine
Perphenazine

Side Effects to Know (NCLEX Favorites)

1. Extrapyramidal Symptoms (EPS)

Dystonia (muscle spasms)
Akathisia (restlessness)
Parkinsonism (tremor, rigidity)
Tardive dyskinesia (lip smacking, tongue movement)

2. Neuroleptic Malignant Syndrome (Life-Threatening)

Signs:

High fever
Muscle rigidity
Altered mental status
Autonomic instability

Nursing action: Stop medication → notify provider → cooling → fluids → supportive care.

3. Anticholinergic Effects

Dry mouth
Blurred vision
Constipation
Urinary retention

4. Orthostatic Hypotension and Sedation

These effects require close monitoring, especially in older adults.

Second-Generation Antipsychotics (Atypical)

These medications block dopamine and serotonin receptors, which helps reduce both positive AND negative symptoms of schizophrenia.

Common Second-Gen Drugs

Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Clozapine (Clozaril)
Aripiprazole (Abilify) – partial dopamine agonist

Side Effects to Know (NCLEX Must-Know)

1. Metabolic Syndrome

Weight gain
Hyperlipidemia
Insulin resistance
Risk for diabetes

2. Sedation & Dizziness

Especially with quetiapine.

3. Orthostatic Hypotension

4. Agranulocytosis (Clozapine Only – Life-Threatening)

Low WBC count
Risk for infection

Nursing action:
Monitor ANC weekly → report fever or sore throat immediately.

5. Fewer EPS Symptoms

Compared to first-gen medications.

First-Gen vs Second-Gen Antipsychotics: Simple Comparison Table

Feature	First-Gen (Typical)	Second-Gen (Atypical)
Main Action	Dopamine blockade	Dopamine & serotonin blockade
Works Best For	Positive symptoms	Positive & negative symptoms
Key Side Effects	EPS, NMS	Metabolic syndrome, sedation
EPS Risk	High	Low
Example Drugs	Haldol, Thorazine	Risperidone, Seroquel
Life-Threatening Risk	NMS	Agranulocytosis (Clozapine)

NCLEX Nursing Tips for Antipsychotics

These points show up repeatedly on NCLEX questions:

1. Monitor for EPS When Giving First-Gen Drugs

Especially after starting haloperidol.

2. Prioritize Airway in Severe Dystonia

Neck stiffness or tongue protrusion can obstruct airway.

3. Report Signs of NMS Immediately

High fever + rigidity = medical emergency.

4. Monitor Weight, Glucose, and Lipids for Second-Gen

Metabolic syndrome develops silently.

5. Educate Patients About Slow Improvement

Symptoms improve gradually over weeks.

6. Avoid Alcohol and CNS Depressants

They increase sedation and respiratory depression risk.

7. Ensure Good Medication Adherence

Stopping antipsychotics abruptly can trigger relapse.

8. Check WBCs Frequently for Clozapine

Teach patients to report fever right away.

Nursing Responsibilities (For RN Nurse Practice)

Every registered nurse caring for patients on antipsychotics must:

1. Assess Mental Status Regularly

Track hallucinations, delusions, mood, and behavior.

2. Monitor Vitals

Blood pressure changes are common.

3. Review Lab Results

WBC count (clozapine)
Lipids
Fasting glucose

4. Watch for Suicidal Thinking

Especially at the beginning of treatment.

5. Provide Medication Teaching

Purpose of the drug
Expected timeline for improvement
Early signs of adverse effects
Importance of follow-up appointments

Patient Teaching (NCLEX Style)

Tell Patients to Report:

Muscle stiffness
Fever
Severe sore throat
Sudden weight gain
Restlessness
Abnormal movements
Difficulty urinating

Lifestyle Teaching

Stay hydrated
Change positions slowly
Exercise regularly
Eat balanced meals
Avoid overheating

NCLEX Rapid Review Box

First-gen antipsychotics → high EPS risk
Second-gen antipsychotics → high metabolic syndrome risk
Clozapine → agranulocytosis
Haloperidol → monitor for acute dystonia
NMS → stop drug, notify provider, treat fever
Risperidone → weight gain + hyperlipidemia
Avoid alcohol and sedatives

FAQ

1. Which antipsychotics have the highest EPS risk?

First-generation antipsychotics like haloperidol and fluphenazine.

2. Which antipsychotic is most likely to cause weight gain?

Second-generation drugs, especially olanzapine and quetiapine.

3.What lab must nurses check for clozapine therapy?

ANC (absolute neutrophil count) to monitor for agranulocytosis.

4. How long do antipsychotics take to work?

Most take 2–6 weeks to improve symptoms.

5. Are antipsychotics safe in pregnancy?

Some are, but always follow provider guidance; avoid abrupt discontinuation.

Antipsychotics: First-Gen vs Second-Gen Nursing Tips