A client with chronic undifferentiated schizophrenia is receiving an antipsychotic medication haloperidol. The client is not sitting still and moving inside and outside the ward. For which potentially extra-pyramidal side effect should a nurse monitor the client?

1. A

   Akathisia

2. B

   Oculogyric crisis

3. C

   Tardive dyskinesia

4. D

   Pseudo parkinsonism

Appeared in: NORCET -4 , 2023

Explanation

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• The client's behavior of being unable to sit still and constantly moving directly corresponds to the definition of akathisia.
• Akathisia is a well-known extrapyramidal side effect (EPS) caused by dopamine-blocking agents like haloperidol.
• It is characterized by a subjective feeling of inner restlessness and a compelling objective need to be in constant motion.

Why Other Options Were Wrong

• Option B: Oculogyric crisis is a form of acute dystonia involving the eyes, specifically prolonged, involuntary upward deviation of the eyeballs. It does not involve generalized body restlessness or pacing.
• Option C: Tardive dyskinesia is a late-onset side effect, developing after long-term antipsychotic use. It is characterized by involuntary, repetitive movements, especially of the face, tongue, and lips (e.g., lip-smacking, grimacing).
• Option D: Pseudo-parkinsonism involves symptoms that mimic Parkinson's disease, such as a resting tremor, muscle rigidity, slowness of movement (bradykinesia), and a shuffling gait. The patient's presentation is one of hyperactivity, not slowness.

Related Visual

• Visual 1: Table: Comparison of Extrapyramidal Symptoms (EPS). A table showing the four main types of EPS (Acute Dystonia, Akathisia, Pseudo-parkinsonism, Tardive Dyskinesia) with their key features, onset time, and classic presentation to help differentiate them.
• Visual 2: Illustration: Patient with Akathisia. A simple drawing showing a person pacing back and forth, unable to sit on a chair, illustrating the characteristic motor restlessness.

Clinical Relevance

• Nursing practice connection: Use the key finding related to Identification of extrapyramidal side effects of antipsychotic medication to guide bedside assessment, documentation, and the next nursing action.
• A critical nursing responsibility is to differentiate akathisia from an exacerbation of psychosis. Mistaking akathisia for agitation and increasing the antipsychotic dose will worsen the patient's distress and the symptom itself.
• Patient safety is a major concern. The constant movement can lead to physical exhaustion, dehydration, and an increased risk of falls. Nurses must monitor the patient's physical status and ensure a safe environment.
• What if the patient was also complaining of a dry mouth, blurred vision, and constipation? These are anticholinergic side effects, also common with antipsychotics. While important to manage, the most distressing and prominent symptom described in the stem is the motor restlessness, making akathisia the primary concern to address.

How to Approach the Question

• First, identify the core components of the clinical scenario: the patient's condition (schizophrenia), the medication (haloperidol), and the presenting symptoms (restlessness, inability to sit still).
• Recognize that haloperidol is a first-generation (typical) antipsychotic with a high risk of causing extrapyramidal side effects (EPS).
• Analyze the specific symptoms. 'Not sitting still' and 'moving inside and outside' are hallmark signs of motor restlessness.
• Evaluate each option against the patient's symptoms:
• Akathisia: Characterized by motor restlessness. This is a strong match.
• Oculogyric crisis: Involves eye muscles. This does not match.

Concept Tested & Keywords

• Concept Tested: Identification of extrapyramidal side effects of antipsychotic medication.
• Stem keywords: chronic undifferentiated schizophrenia, haloperidol, not sitting still, moving inside and outside, extra-pyramidal side effect
• Lead-in keywords: monitor
• Clinical cues: The patient is on haloperidol, a typical antipsychotic known for causing EPS.
• Clinical cues: The key symptom is motor restlessness ('not sitting still', 'moving inside and outside').

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