Chapter 34: Sedative-Hypnotic Drugs
A nurse is discussing the use of benzodiazepines as sedative-hypnotic agents with a group of nursing students. A student asks about the actions of these drugs in the central nervous system. The nurse makes which correct statement? a. "Benzodiazepines affect the hippocampus and the cerebral cortex to cause anterograde amnesia." b. "Benzodiazepines depress neuronal functions by acting at a single site in the brain." c. "Benzodiazepines induce muscle relaxation by acting on sites outside the central nervous system." d. "Benzodiazepines promote sleep through effects on the limbic system."
A All beneficial and most adverse effects of benzodiazepines occur from depressant actions in the central nervous system (CNS); the various effects depend on the site of action. Anterograde amnesia is the result of effects in the hippocampus and the cerebral cortex. Benzodiazepines act at multiple sites in the CNS. Muscle relaxant effects are the result of actions on supraspinal motor areas in the CNS. Benzodiazepines promote sleep through effects on cortical areas and on the sleep-wakefulness "clock."
A patient with a new-onset seizure disorder receives a prescription for phenobarbital. The patient reports being concerned about the sedative side effects of this drug. Which response by the nurse is correct? a. "Phenobarbital doses for seizures are nonsedating." b. "This is a short-acting barbiturate, so sedation wears off quickly." c. "Tolerance to the sedative effects will develop in a few weeks." d. "You may actually experience paradoxical effects of euphoria."
A Phenobarbital and mephobarbital are used for seizure disorders and suppress seizures at doses that are nonsedative. Phenobarbital is a long-acting barbiturate. At therapeutic doses, sedative effects do not occur. Paradoxical drug effects are associated with benzodiazepines and in older adults and debilitated patients with barbiturates.
A patient takes temazepam [Restoril] for insomnia. The patient tells the nurse that a recent telephone bill lists several calls to friends that the patient does not remember making. What will the nurse do? a. Ask the patient about any alcohol consumption in conjunction with the benzodiazepine. b. Contact the prescriber to request an order for a benzodiazepine with a shorter duration. c. Reassure the patient that this is most likely caused by a paradoxical reaction to the benzodiazepine. d. Tell the patient that this is an example of anterograde amnesia, which is an expected effect of the benzodiazepine.
A This patient is describing complex sleep-related behavior, which occurs when patients carry out complex behaviors while taking benzodiazepines but have no memory of their actions. These actions can occur with normal doses but are more likely with excessive doses or when benzodiazepines are combined with alcohol or other CNS depressants, so the nurse is correct in evaluating this possibility. The duration of the benzodiazepine does not contribute to this phenomenon. Paradoxical effects of benzodiazepines include insomnia, excitation, euphoria, anxiety, and rage. Anterograde amnesia occurs when patients have impaired recall of events that occur after dosing.
Which sedative-hypnotics are useful for both difficulty falling asleep and difficulty maintaining sleep? (Select all that apply.) a. Eszopiclone [Lunesta] b. Flurazepam [Dalmane] c. Temazepam [Restoril] d. Triazolam [Halcion] e. Extended-release zolpidem [Ambien CR]
A, B, E Eszopiclone [Lunesta], flurazepam, and extended-release zolpidem [Ambien CR] help with difficulty falling asleep and difficulty maintaining sleep. Temazepam is useful for maintaining sleep only. Triazolam helps with difficulty falling asleep but does not maintain sleep.
A nurse is obtaining a health history from an older adult patient in an outpatient clinic. The patient reports chronic difficulty falling asleep and staying asleep. The nurse knows that the best treatment for this patient will be: a. alternative medications. b. improved sleep hygiene. c. short-term barbiturates. d. triazolam [Halcion].
B Research has shown that cognitive behavioral therapy is superior to drug therapy for short-term and long-term management of chronic insomnia in older adults. Alternative remedies have not been proven effective. Barbiturates may elicit paradoxical effects in elderly patients. Triazolam does not help to maintain sleep.
A patient complains of chronic insomnia and reports being tired of being tired all the time. The patient is reluctant to try pharmacologic remedies and asks the nurse what to do. What will the nurse suggest? a. "Eat a large meal in the evening to induce drowsiness." b. "Get out of bed for a while if you can't fall asleep." c. "Have a glass of wine at bedtime to relax." d. "Take a short nap early in the afternoon every day."
B Rules for sleep fitness recommend getting out of bed if unable to fall asleep in 20 minutes and doing something relaxing and then returning to bed when drowsy. Eating a large meal will increase insomnia. Drinking alcohol helps some people to fall asleep but causes fragmented sleep. Taking a nap reduces feelings of drowsiness at bedtime.
A nurse recognizes that the actions of benzodiazepines include which findings? (Select all that apply.) a. Sleep deprivation b. Relief of general anxiety c. Suppression of seizures and/or seizure activity d. Development of tardive dyskinesia e. Increase in muscle spasms
B, C Benzodiazepines are indicated to relieve the symptoms of general anxiety and to suppress the central nervous system, thereby suppressing seizures and/or seizure activity. Benzodiazepines cause sleepiness, not sleep deprivation. Benzodiazepines do not cause tardive dyskinesia. Benzodiazepines relax muscles; they do not increase muscle spasms.
A patient is brought to the emergency department by friends, who say that they were at a party where alcohol and a mix of barbiturates and benzodiazepines were all available. They tell the nurse that the patient was among the first to arrive at the party, which started several hours ago. The patient is nonresponsive and has pinpoint pupils and respirations of 6 breaths per minute. After oxygen has been administered, the nurse should prepare the patient for which intervention? a. A central nervous system stimulant and IV fluids b. Activated charcoal and flumazenil [Romazicon] c. Maintaining adequate oxygenation to the brain d. Naloxone [Narcan] and a cathartic
C Because time has elapsed, enough medication is present in the system to warrant treatment for systemic effects. A central nervous system stimulant is contraindicated, and intravenous fluids do not address the overdose. Although activated charcoal may assist in absorption of medication in the gut, flumazenil will be effective only for the benzodiazepines. Naloxone, a narcotic antagonist, is not effective for barbiturates and benzodiazepines.
A patient has been taking high doses of clorazepate [Tranxene] for several months for an anxiety disorder. The nurse assessing the patient observes that the patient is agitated, euphoric, and anxious. What will the nurse do? a. Double-check the chart to make sure the last dose was given. b. Request an order for a longer-acting benzodiazepine. c. Suspect a possible paradoxical reaction to the clorazepate. d. Withhold the next dose until a drug level can be drawn.
C Patients taking benzodiazepines for anxiety sometimes develop paradoxical responses to the drug, which include insomnia, excitation, euphoria, heightened anxiety, and rage. A missed dose would trigger withdrawal symptoms, which would include anxiety, insomnia, sweating, tremors, and dizziness. Because this is a paradoxical reaction to the drug, a longer-acting drug would make the symptoms worse. This is not caused by overdose, which would manifest as drowsiness, lethargy, and confusion, so a drug level is not warranted.
A patient with a history of depression and suicidal ideation is taking fluoxetine [Prozac]. The patient reports difficulty maintaining sleep and is prescribed secobarbital [Seconal] as a sedative-hypnotic. The nurse preparing this patient for discharge from the hospital will: a. contact the provider to suggest an order for ramelteon [Rozerem]. b. instruct the patient to use alcohol in moderation. c. request an order to change to trazodone [Desyrel] for sleep. d. suggest that the patient try alternative remedies for sleep.
C Trazodone is an atypical antidepressant with sedative actions and can be used to prolong sleep duration. It is useful for treating insomnia related to antidepressants such as Prozac. Ramelteon is not a drug of choice to treat patients who have difficulty maintaining sleep. Patients who are depressed or at increased risk for suicide should not take barbiturates, because overdose can readily cause death. Alcohol is contraindicated when taking barbiturates. Alternative remedies have not shown effectiveness in treating insomnia.
A patient in the emergency department is given intravenous diazepam [Valium] for seizures. When the seizures stop, the nurse notes that the patient is lethargic and confused and has a respiratory rate of 10 breaths per minute. The nurse will expect to administer which of the following? a. Flumazenil [Romazicon] b. Gastric lavage c. Respiratory support d. Toxicology testing
C When benzodiazepines are administered IV, severe effects, including profound hypotension, respiratory arrest, and cardiac arrest, can occur. Respiration should be monitored, and the airway must be managed if necessary. Flumazenil [Romazicon] is a competitive benzodiazepine receptor antagonist and is used to reverse the sedative effects but may not reverse respiratory depression. Gastric lavage would not be effective, because the benzodiazepine has been given IV. Without further indication of the ingestion of other drugs, toxicology testing is not a priority.
A patient who travels frequently for business reports occasional instances of being unable to fall asleep. The patient tells the nurse that job demands require staying up late and then getting up early for meetings. The nurse expects that the provider will prescribe which medication for this patient? a. Flurazepam b. Trazodone [Desyrel] c. Zaleplon [Sonata] d. Zolpidem [Ambien]
C Zaleplon [Sonata] works well for people who have trouble falling asleep and, because of its short duration of action, can be taken late at night without causing a hangover or next-day sedation early in the morning. Zolpidem [Ambien] has a longer duration and is a good choice for patients who have difficulty maintaining sleep. Flurazepam has a long duration of action. Trazodone causes daytime grogginess.
A patient who is experiencing alcohol withdrawal is given a benzodiazepine. The nurse understands that this drug is effective because: a. the alcohol does not interact with the benzodiazepine. b. the benzodiazepine potentiates alcohol withdrawal symptoms. c. the benzodiazepine relieves muscle spasms and spasticity. d. the patient has a cross-dependence to the benzodiazepine.
D Benzodiazepines are given to ease withdrawal from alcohol because of cross-dependence with these drugs and alcohol, enabling the benzodiazepine to suppress withdrawal symptoms. Alcohol and benzodiazepines can potentiate one another. The benzodiazepine does not potentiate withdrawal symptoms. Benzodiazepines relieve muscle spasms, but this is not why they are given for alcohol withdrawal.
A patient who has been using secobarbital for several months to treat insomnia tells the nurse that the prescriber has said the prescription will be changed to temazepam [Restoril] because it is safer. The patient asks why this agent is safer. The nurse is correct in telling the patient that temazepam: a. does not depress the central nervous system. b. shows no respiratory depression, even in toxic doses. c. mimics the actions of a central nervous system inhibitory neurotransmitter. d. potentiates endogenous gamma-aminobutyric acid (GABA) producing a finite CNS depression.
D Benzodiazepines potentiate the actions of GABA, and because the amount of GABA in the CNS is finite, these drugs' depressive effect on the CNS is limited. Benzodiazepines depress the CNS but not to the extent that barbiturates do. Benzodiazepines are weak respiratory depressants at therapeutic doses and moderate respiratory depressants at toxic doses. Barbiturates mimic GABA; therefore, because they produce CNS depression, this effect is limited only by the amount of barbiturate administered.
A hospitalized patient who is given one dose of flurazepam continues to show drowsiness the next day. A nursing student asks the nurse the reason for this, because the drug's half-life is only 2 to 3 hours. Which response by the nurse is correct? a. "Benzodiazepines commonly cause residual effects lasting into the day after the dose is given." b. "The patient is having a paradoxical reaction to this medication." c. "This patient must have developed a previous tolerance to benzodiazepines." d. "When this drug is metabolized, the resulting compound has longer-lasting effects."
D Flurazepam has a half-life of 2 to 3 hours; however, its metabolite has a long half-life, so giving the drug results in long-lasting effects. Barbiturates, not benzodiazepines, are commonly associated with residual, or hangover, effects. A paradoxical reaction to a sedative would manifest as insomnia, euphoria, and excitation, not drowsiness. Tolerance means that the patient would need increased amounts of a drug to get the desired effects and would not have prolonged effects of the medication.