Positive, negative and cognitive symptoms
Schizophrenia is a chronic disorder with disturbances in thought, perception, affect and behaviour. Positive symptoms are experiences added to normal function: hallucinations, most often auditory; delusions, including persecutory, grandiose, somatic and referential types; disorganised speech such as loose associations, word salad, neologisms, clang associations and echolalia; and disorganised or catatonic behaviour.
Negative symptoms are functions lost: flat or blunted affect, alogia or poverty of speech, avolition or lack of goal-directed activity, anhedonia and asociality. These respond less well to medication, contribute most to long-term disability, and are easily mistaken for depression or laziness. Cognitive symptoms include impaired attention, working memory and executive function.
The exam often asks which symptom cluster a described behaviour belongs to, or which finding indicates improvement. Reduced hallucination frequency shows response to antipsychotics; renewed grooming, initiating conversation and attending group show improvement in negative symptoms and typically take longer.
| Category | Examples | Treatment response |
|---|---|---|
| Positive | Hallucinations, delusions, disorganised speech | Usually good with antipsychotics |
| Negative | Flat affect, avolition, alogia, anhedonia | Slower, partial; psychosocial support matters |
| Cognitive | Poor attention, memory, executive function | Limited; structure and cues help |
| Mood-related | Depression, suicide risk | Assess directly and repeatedly |
Responding to hallucinations and delusions
The tested rule is that the nurse neither argues nor colludes. When a client reports hearing voices, ask what the voices are saying — this assesses for command hallucinations and safety risk — then state calmly that you do not hear the voices but you believe the client hears them, and redirect to a reality-based activity. Saying that the voices are not real dismisses the experience; agreeing that you hear them reinforces the psychosis. Both are wrong answers.
With delusions, focus on the underlying feeling rather than the content. A client convinced staff are poisoning the food is frightened, and the therapeutic response acknowledges the fear, avoids debate, and offers a practical accommodation such as sealed packaged food and observed preparation. Logical argument entrenches delusions and damages trust.
Safety drives priority. Command hallucinations instructing self-harm or harm to others require immediate assessment, close observation and provider notification. Increasing agitation, pacing, clenched fists, escalating volume and invading personal space signal impending aggression; respond with a calm voice, a non-threatening stance, adequate personal space, an exit route for both parties, and offers of a quiet area and medication before restrictive measures. Restraints and seclusion are last resorts with an order, continuous monitoring and documentation.
- •Ask what the voices are saying — assess for commands
- •State your own reality once, without debate
- •Address feelings behind delusions, not content
- •Keep communication concrete, brief and clear
- •Maintain space and a calm tone with escalating clients
- •Least restrictive intervention first, always
Antipsychotics and their side effects
First-generation antipsychotics such as haloperidol, fluphenazine and chlorpromazine control positive symptoms but carry a high risk of extrapyramidal symptoms. Second-generation agents such as risperidone, olanzapine, quetiapine, ziprasidone and aripiprazole treat positive and some negative symptoms with fewer movement effects but greater metabolic risk, requiring weight, glucose, lipid and blood pressure monitoring.
Extrapyramidal symptoms follow a predictable timeline. Acute dystonia — muscle spasm of the neck, jaw, eyes or back — appears within hours to days and is treated urgently with intramuscular benztropine or diphenhydramine, since laryngeal spasm can compromise the airway. Akathisia, an inner restlessness with inability to sit still, appears within days to weeks and may be mistaken for agitation; treatment includes dose reduction or a beta blocker. Pseudoparkinsonism with tremor, rigidity and shuffling gait appears within weeks and responds to anticholinergics. Tardive dyskinesia, with involuntary lip smacking, tongue movements and grimacing, appears after months to years and may be irreversible, so it is screened for regularly and reported promptly.
Neuroleptic malignant syndrome is the emergency: high fever, severe lead-pipe muscle rigidity, altered mental status, autonomic instability with labile blood pressure and tachycardia, and a raised creatine kinase. Stop the antipsychotic, notify the provider immediately, and support with cooling, hydration and monitoring. Do not confuse it with serotonin syndrome, which features hyperreflexia, clonus and agitation with serotonergic drugs.
Clozapine and long-acting injectables
Clozapine is reserved for treatment-resistant schizophrenia and reduces suicide risk, but requires strict monitoring for agranulocytosis through scheduled absolute neutrophil counts. The client is taught to report fever, sore throat, flu-like symptoms or any sign of infection immediately. Other clozapine effects include significant sedation, hypersalivation, weight gain, constipation that can become severe ileus, seizures at higher doses, and myocarditis.
Long-acting injectable formulations improve adherence in clients who stop oral medication, and are given at intervals of two to four weeks or longer. Teaching covers appointment adherence, the fact that side effects persist for the duration of the depot, and reporting movement symptoms between visits.
General adherence support includes simplifying regimens, treating side effects rather than dismissing them, involving family, using community mental health follow-up and case management, and setting expectations that antipsychotics reduce symptoms over weeks rather than instantly.
Community care, teaching and exam patterns
Relapse prevention is a common teaching topic. Early warning signs include sleep disturbance, social withdrawal, increased suspiciousness and reduced self-care. Clients and families learn to seek help at these signs rather than waiting for full relapse. Substance use, particularly cannabis and stimulants, worsens outcomes and is addressed. Smoking is common and induces hepatic enzymes, which can reduce levels of some antipsychotics — a detail that appears in medication items.
Social skills training, supported employment, structured day programmes and family psychoeducation improve functioning. Nurses reinforce that schizophrenia is a medical illness, counter stigma, and coordinate with community teams for housing, benefits and continuity of medication.
On the exam, the pattern is reliable: a stem with fever and rigidity on an antipsychotic is NMS; a stem with a stiff neck or eyes rolled upward hours after a dose is acute dystonia; a stem with lip smacking after years is tardive dyskinesia; a stem with a voice telling the client to hurt someone is a safety priority; and a stem asking how to respond to a delusion wants acknowledgement plus reality plus redirection.