Karch's PrepU (Pharm) CH. 20: Anxiolytic and Hypnotic Agents
A female client is prescribed a benzodiazepine for anxiety. She asks the nurse if she can stop the drug when she feels better. What is the nurse's best response? "Benzodiazepines do not cause physiologic dependence, and withdrawal symptoms will not occur if the drug is stopped abruptly." "Benzodiazepines may cause physiologic dependence, but withdrawal symptoms will not occur if the drug is stopped abruptly." "Benzodiazepines may cause physiologic dependence, and withdrawal symptoms will occur if the drug's dosages are tapered." "Benzodiazepines may cause physiologic dependence, and withdrawal symptoms will occur if the drug is stopped abruptly."
"Benzodiazepines may cause physiologic dependence, and withdrawal symptoms will occur if the drug is stopped abruptly." Explanation: Benzodiazepines are widely used for anxiety and insomnia and are also used for several other indications. They have a wide margin of safety between therapeutic and toxic doses and are rarely fatal, even in overdose, unless combined with other CNS depressant drugs, such as alcohol. They are schedule IV drugs under the Controlled Substances Act. They are drugs of abuse and may cause physiologic dependence; therefore, withdrawal symptoms occur if the drugs are stopped abruptly.
A hospitalized client asks the nurse why the health care provider prescribed an anxiolytic medication. What is the nurse's best response? "An anxiolytic, such as alprazolam, is usually prescribed for long-term anxiety disorders." "This type of medication is typically prescribed to treat excess anxiety that interferes with daily activities." "Anxiolytics are prescribed to treat anxiety and can be purchased without a prescription after discharge." "Anxiolytic drugs are different from antianxiety drugs, because they work without a tranquilizing effect."
"This type of medication is typically prescribed to treat excess anxiety that interferes with daily activities." Explanation: Drugs used to treat anxiety are called antianxiety, or anxiolytic, drugs. Long-term use of benzodiazepines, such as Xanax, can result in physical or psychological dependence. Due to the risk of dependence, benzodiazepines are used for short-term anxiety relief. Due to the risk of dependence, anxiolytics are classified as schedule IV controlled substances. Therefore, anxiolytics require a prescription. Anxiolytic drugs exert their tranquilizing effect by blocking certain neurotransmitter sites.
A client is experiencing acute anxiety and the nurse has received an order for diazepam 4 mg PO STAT. What is the nurse's best action? Administer the medication as prescribed Contact the prescriber to confirm the dose Contact the prescriber to confirm the route Ensure flurazepam is available
Administer the medication as prescribed Explanation: This order is within expected parameters for dose and route, so there is no obvious need to contact the prescriber. Flumazenil, not flurazepam, is the antidote for benzodiazepine overdose.
The nurse is caring for a client who is receiving an intravenous barbiturate. What assessment should the nurse prioritize? Blood pressure Oxygen saturation Assessment for bleeding Anaphylaxis
Blood pressure Explanation: Hypotension is a possible effect when barbiturates are given IV and is more common than hypoxia. Bleeding is not associated with intravenous barbiturate use. Anaphylaxis would be a serious but rare occurrence.
The nurse is doing a physical assessment on admission of a client diagnosed with elevated blood pressure due to anxiety. What are the most important physical assessments for a nurse to perform? Select all that apply. Blood pressure Bowel sounds Respiratory rate Skin temperature and color Hair texture
Blood pressure Bowel sounds Skin temperature and color Explanation: During the intake exam, a focused physical assessment for anxiety should include checking blood pressure, pulse, respiratory rate, and weight. Physiologic manifestations of anxiety can include increased blood pressure and pulse rate, increased rate and depth of respiration, and increased muscle tension. An anxious client may have cool and pale skin. Bowel sounds and hair texture would not be as important as assessing blood pressure, respiratory rate, and skin temperature for the client who is anxious.
What should the nurse's pre-administration physical assessment for the administration of an anxiolytic include? (Select all that apply.) Blood pressure Blood glucose Pulse Respiratory rate Weight
Blood pressure Pulse Respiratory rate Weight Explanation: The nurse's pre-administration physical assessment for the administration of an anxiolytic should include blood pressure, pulse, respiratory rate, and weight.
Which agent has no sedative, anticonvulsant, or muscle relaxant properties but does reduce the signs and symptoms of anxiety? Diphenhydramine Zaleplon Buspirone Meprobamate
Buspirone Explanation: Buspirone has no sedative, anticonvulsant, or muscle relaxant properties, but it does reduce the signs and symptoms of anxiety. Diphenhydramine is an antihistamine that can be sedating. Zaleplon causes sedation and is used for short-term treatment of insomnia. Meprobamate has some anticonvulsant properties and CNS-relaxing effects.
A client with a high-pressure job temporarily requires an anxiolytic that has no sedative properties. What medication is most likely to meet this client's needs? Buspirone Zaleplon Meprobamate Diphenhydramine
Buspirone Explanation: Buspirone has no sedative, anticonvulsant, or muscle relaxant properties, but it does reduce the signs and symptoms of anxiety. Zaleplon causes sedation and is used for short-term treatment of insomnia. Meprobamate has some anticonvulsant properties and central nervous system relaxing effects. Diphenhydramine is an antihistamine that can be sedating.
The nurse should not administer sedatives or hypnotic drugs to which client? Client with a history of asthma Comatose client Woman of childbearing age Client with an egg allergy
Comatose client Explanation: The nurse should not administer these drugs to comatose clients, those with severe respiratory problems, those with a history of habitual drug and alcohol use, or pregnant or lactating women. The nurse could safely administer sedatives or hypnotics to a client with a history of asthma as long as the client is not having an acute attack. A woman of childbearing age can receive sedatives or hypnotics after it is confirmed she is not currently pregnant. An egg allergy is not a contraindication to sedative or hypnotic administration.
An older adult client is prescribed a sedative for the treatment of insomnia. The nurse would suspect that the client is experiencing an adverse reaction to the drug based on assessment of which of the following? Headache Stress Confusion Anxiety
Confusion Explanation: The nurse should look for signs of confusion in an older adult client when monitoring the effects of the administered drug. Headache, stress, and anxiety are causes of insomnia.
In addition to relieving agitation and anxiety, what is a rationale for using benzodiazepines in the treatment of a critically ill client? Increased diffusion and perfusion Decreased cardiac workload Increased level of consciousness Decreased blood pH
Decreased cardiac workload Explanation: Antianxiety and sedative-hypnotic drugs are often useful in critically ill clients to relieve stress, anxiety, and agitation. Their calming effects decrease cardiac workload (e.g., heart rate, blood pressure, force of myocardial contraction, myocardial oxygen consumption) and respiratory effort. They do not decrease blood pH, increase diffusion and perfusion, or increase level of consciousness.
A nurse has noted that a newly admitted client has been taking ramelteon for the past several weeks. The nurse is justified in suspecting that this client was experiencing what problem prior to starting this drug? Somnambulism Difficulty falling asleep at night Early morning waking Frequent nighttime awakenings
Difficulty falling asleep at night Explanation: Ramelteon is use for the long-term treatment of insomnia characterized by difficulty with sleep onset. Ramelteon is not effective in managing any of the other suggested sleep-related issues.
Clients taking benzodiazepines, especially older adult clients, are at high risk for which effect? Falls Constipation Heart failure Hepatic failure
Falls Explanation: Clients taking benzodiazepines, especially older adult clients, are at high risk for falls and should be counseled on fall prevention measures. Constipation can occur at any time in an older adult due to the lack of fluid or fiber intake. Benzodiazepine use does not indicate high risk for heart failure or hepatic failure.
An older adult client diagnosed with generalized anxiety disorder is prescribed a benzodiazepine. The nurse caring for the client knows to include what intervention in the client's care plan? Seizure precautions Falls risk assessment Frequent dysrhythmias monitoring Education regarding sexual dysfunction
Falls risk assessment Explanation: Adverse effects of benzodiazepines (e.g., drowsiness, dizziness) may contribute to falls and other injuries unless clients are carefully monitored and safeguarded. Seizures, dysrhythmias, and sexual dysfunction are not characteristic adverse effects.
Eszopiclone is thought to react with norepinephrine to achieve its action. True False
False Explanation: Eszopiclone is thought to react with GABA sites near benzodiazepine receptors.
A nurse is caring for an elderly patient undergoing antianxiety treatment. The patient is to be administered antianxiety drugs parenterally. What precautions should be taken by the nurse? Arrange for a blood transfusion. Provide fiber-rich food. Provide plenty of fluids. Have resuscitative equipment ready.
Have resuscitative equipment ready. Explanation: The nurse should have resuscitative equipment ready because elderly patients may experience apnea and cardiac arrest during the treatment. Providing fiber-rich food and plenty of fluids is not a precautionary measure during the parenteral administration of the drug. The need for a blood transfusion would not arise during the treatment.
A nurse is caring for a patient who has been administered a barbiturate. Which is a symptom of barbiturate toxicity that the nurse must monitor the patient for? Restlessness Euphoria Hypotension Confusion
Hypotension Explanation: The nurse must monitor the patient for hypotension, which is one of the symptoms of barbiturate toxicity. Restlessness, euphoria, and confusion are withdrawal symptoms seen in the use of sedatives and hypnotics.
A patient admitted to the health care facility for alcohol withdrawal has been prescribed an antianxiety medication. Why should the nurse suggest the patient stop consuming alcohol while therapy is ongoing? Increased risk for digitalis toxicity Increased risk for respiratory depression Increased risk for sedation Increased risk for central nervous system depression
Increased risk for central nervous system depression Explanation: The nurse should suggest that the patient stop consuming alcohol while therapy is going on because such consumption increases the risk for CNS depression. Increased risk for digitalis toxicity is identified when the patient is taking digoxin for management of cardiac problems. Increased risk for sedation and respiratory depression is identified when tricyclic antidepressants or antipsychotics are being used simultaneously.
The client suffers from GERD and diverticulosis and has been admitted to a medical floor. The admitting physician orders cimetidine and a sedative to calm the client. What should the nurse be concerned about? Decreased sedative effect Increased sedative effect If the client's insurance will cover the two drugs Cost of the drugs
Increased sedative effect Explanation: An increased sedative effect may occur when a sedative is given with cimetidine for gastric upset. The other options do not play a role in providing the best care for the client.
A nurse is caring for a patient who is prescribed flurazepam. Which is an effect of flurazepam? Decreases stress Eases pain Induces sleep Improves circulation
Induces sleep Explanation: Flurazepam induces sleep. Adrenergic drugs help to relieve stress. Analgesics are used to ease pain. Circulation can be improved by exercising.
After reviewing the various drugs that are classified as barbiturates, a student demonstrates understanding when identifying which as the prototype? Amobarbital Secobarbital Pentobarbital Phenobarbital
Phenobarbital Explanation: Phenobarbital is considered the prototype barbiturate.
A client in intensive care has been prescribed both lorazepam and hydromorphone. The nurse should prioritize what assessments for the client? Arterial blood gases Respiratory rate and oxygen saturation Deep tendon reflexes and pupillary response Cardiac rate and rhythm
Respiratory rate and oxygen saturation Explanation: The combination of opioids and benzodiazepines creates a significant risk for central nervous system depression; respiratory function is consequently an important focus of assessment. It would likely supersede other assessments, even though each may be warranted.
What medication is thought to play a role in maintenance of the circadian rhythm? Sonata Ambien Rozerem Kava
Rozerem Explanation: Rozerem is an oral nonbenzodiazepine hypnotic approved for the long-term treatment of insomnia characterized by difficulty with sleep onset. Unlike other nonbenzodiazepine hypnotics that bind to GABA<A receptors, ramelteon binds to melatonin receptors in the central nervous system. Stimulation of melatonin receptors by ramelteon, like endogenous melatonin, is thought to play a role in the maintenance of the circadian rhythm that helps regulate the normal sleep-wake cycle.
An older adult client presents to the clinic and is diagnosed with generalized anxiety disorder (GAD). The health care provider (HCP) orders oral flurazepam 30 mg PO at bedtime. What is the nurse's priority action? Teach the client about the prescribed medication. Administer the first dose of medication. Tell the client to take first dosage after driving home. Talk to the HCP about the dosage.
Talk to the HCP about the dosage. Explanation: If an anxiolytic or hypnotic agent is the drug of choice for an older adult client, the smallest possible dose should be used, and the client should be monitored very closely during the first week of treatment. Dosage adjustments are necessary to achieve the most effective dose with the fewest adverse effects. In addition, older adults also require careful titration of dosage. Older clients may be more susceptible to the adverse effects of these drugs, from unanticipated central nervous system (CNS) adverse effects including increased sedation, dizziness, and even hallucinations. Dosages of all of these drugs should be reduced, and the client should be monitored very closely for toxic effects and to provide safety measures if CNS effects do occur. As a result, the priority action is to talk to the HCP about the dosage. The other actions may be appropriate after a proper dosage is ordered.
Three days after discontinuing diazepam with medical guidance, an older adult continues to demonstrate impaired memory and confusion. The nurse should consider what possible explanation for the client's current status? Benzodiazepines can occasionally cause permanent alterations in personality and level of consciousness. The client may have decreased liver function. The client may have been experiencing a hypersensitivity to the drug, rather than an adverse effect. The adverse effects of benzodiazepines can persist for several days after stopping the drug.
The adverse effects of benzodiazepines can persist for several days after stopping the drug. Explanation: Both therapeutic effects and adverse effects of diazepam are more likely to occur after 2 or 3 days of therapy than initially. Such effects accumulate with chronic usage and persist for several days after the drug is discontinued. Hypersensitivity and decreased liver function are unlikely. Benzodiazepines do not cause permanent changes in cognition.
A client diagnosed with an anxiety disorder has expressed dissatisfaction with lorazepam therapy and wants to discontinue the drug. What is the most important information the nurse expects the health care provider to give the client? It will take a minimum of 2 weeks for the drug to leave the system. Symptoms will only improve with medication therapy. The drug should be tapered gradually to prevent severe symptoms of withdrawal. Discontinuing the drug is unwise.
The drug should be tapered gradually to prevent severe symptoms of withdrawal. Explanation: To prevent withdrawal symptoms, lorazepam should be tapered in dose and gradually discontinued. While it may take several weeks for the drug to leave the system, this information is not as critical as the instruction to taper. There are other methods of treating anxiety, so it may not be appropriate to claim that lorazepam therapy is the only solution. Telling the client that discontinuation is unwise fails to account for the client's right to choose, and it doesn't convey the necessary safety information.
A 70-year-old patient has just started taking lorazepam 10 days ago for anxiety issues related the death of her husband. She is staying with her daughter for a couple of weeks. The patient's daughter has noticed that her mother is having difficulty walking and seems to be confused at times and calls the clinic to report this to the nurse. The nurse will inform the daughter that: a dose adjustment should be made if these symptoms persist. the drug should be stopped immediately if these effects persist. the drug should be administered intravenously if these effects persist. no changes should be made at this time; the adverse effects will resolve with continued use.
a dose adjustment should be made if these symptoms persist. Explanation: If ataxia and confusion occur, especially in older adults or in a debilitated patient, dose adjustments should be made if the effects persist. If the drug is stopped immediately, withdrawal symptoms may occur. Intravenous administration or continuing the same dosage and medication would not help relieve ataxia or confusion in the patient.
A client is receiving a barbiturate intravenously. The nurse would monitor the client for: hypertension. bradycardia. tachypnea. bleeding.
bradycardia. Explanation: When given intravenously, barbiturates can result in bradycardia, hypotension, hypoventilation, respiratory depression, and laryngospasm. Bleeding is not associated with barbiturate therapy.
The nurse is providing health education for a client who has been prescribed a benzodiazepine. What adverse effect should the nurse discuss in the teaching? dependence suicide personality changes persistent insomnia
dependence Explanation: Benzodiazepines carry a significant risk for dependence. They do not cause suicidality, personality changes, or insomnia.
What is the prototype for the classification of drugs referred to as benzodiazepines? alprazolam lorazepam diazepam clonazepam
diazepam Explanation: Diazepam is the prototype benzodiazepine. High-potency benzodiazepines such as alprazolam, lorazepam, and clonazepam may be more commonly prescribed due to their greater therapeutic effects and rapid onset of action.
A client who is experiencing acute alcohol withdrawal is being treated with intravenous lorazepam (Ativan). This drug achieves a therapeutic effect by: increasing the effects of the neurotransmitter GABA. inhibiting the action of monoamine oxidase. affecting the regulation of serotonin and norepinephrine in the brain. increasing the amount of serotonin available in the synapses.
increasing the effects of the neurotransmitter GABA. Explanation: Like all benzodiazepines, lorazepam increases the effects of GABA, which has an inhibitory effect on the CNS. However, none of the benzodiazepines act like GABA or increase the amount of GABA present. MAOIs inhibit monoamine oxidase and tricyclic antidepressants primarily affect serotonin and norepinephrine levels. SSRIs increase the availability of serotonin in the synapses.
Buspirone has been prescribed for a client diagnosed with anxiety. When providing health education, the nurse should describe what benefit of this medication over other anxiolytics? decreased risk of hepatic injury less central nervous system depression rapid onset and short duration sublingual administration
less central nervous system depression Explanation: Buspirone is a newer anxiolytic drug that does not cause sedation or muscle relaxation. It is preferred when the client needs to be alert such as when driving or working. Buspirone does not have a reduced risk of hepatic injury relative to other anxiolytics, nor does it have a faster onset and shorter duration. It is administered orally, not sublingually.
An older adult client is brought to the emergency department by family members. The family states the client has been uncharacteristically agitated and restless. The nurse reviews the client's current medication regimen and suspects the client was recently prescribed what medication? lorazepam metoprolol cephalexin acetaminophen
lorazepam Explanation: The adverse effects of benzodiazepines are associated with the impact of these drugs on the central and peripheral nervous systems. Nervous system effects include sedation, drowsiness, depression, lethargy, blurred vision, "sleep driving" and other complex behaviors, headaches, apathy, light-headedness, amnesia, and confusion. In addition, mild paradoxical excitatory reactions may occur during the first 2 weeks of therapy. Paradoxical reactions are an unintended, paradoxical response to a medication. In the case of benzodiazepines, it can result in excessive movements, agitation, talkativeness, impulsivity, irritability, and/or excitement (the opposite of a benzodiazepine's intended effect). Neither antibiotics, beta-blockers, nor acetaminophen are associated with these paradoxical reactions.
One week ago, a 74-year-old was started on a benzodiazepine for the treatment of an anxiety disorder. The client comes into the clinic for a follow-up visit and states feeling nervous, is having trouble sleeping, and feels hyperactive. What does the nurse understand may be occurring as a result of this medication? allergic reaction to the benzodiazepine paradoxical excitement taking too much of the medication (nonadherence) not taking the medication as ordered (noncompliance)
paradoxical excitement Explanation: When beginning drug therapy with a sedative or benzodiazepine to treat anxiety, the older client may experience an effect that is the opposite of intended. This effect is known as paradoxical excitement, whereby the client is wide awake and hyperactive rather than calm and relaxed
One week ago, a 74-year-old was started on a benzodiazepine for the treatment of an anxiety disorder. The client comes into the clinic for a follow-up visit and states feeling nervous, is having trouble sleeping, and feels hyperactive. What does the nurse understand may be occurring as a result of this medication? allergic reaction to the benzodiazepine paradoxical excitement taking too much of the medication (nonadherence) not taking the medication as ordered (noncompliance)
paradoxical excitement Explanation: When beginning drug therapy with a sedative or benzodiazepine to treat anxiety, the older client may experience an effect that is the opposite of intended. This effect is known as paradoxical excitement, whereby the client is wide awake and hyperactive rather than calm and relaxed.
The nurse gives a 68-year-old client diphenhydramine to help the client sleep the night before surgery. At midnight, the nurse notes the client is awake and agitated. What pharmacologic principle would be the cause of this reaction? medication error; the nurse actually gave the wrong medication delayed onset of action due to decreased distribution of the medication paradoxical excitement, which is the opposite reaction than what was expected pronounced effect from the medication due to the inability of the blood-brain barrier to work effectively
paradoxical excitement, which is the opposite reaction than what was expected Explanation: Drug-induced behavioral changes often affect the older adult. Sometimes, they occur unexpectedly. For example, when beginning drug therapy with a sedative or a benzodiazepine to treat anxiety, the older client may experience an effect that is the opposite of the intended effect. This effect is known as paradoxical excitement, where the client is wide awake and hyperactive rather than calm and relaxed. In all probability the nurse did not give the wrong medication, unless she did not follow proper technique when administering it. Delayed gastric emptying has an effect on decreased absorption but may actually increase distribution because of the prolonged transit time in the bowel. The blood-brain barrier is less effective in the older adult, but the nurse would expect a more pronounced effect, not a decreased effect.
A 28-year-old patient is to receive a dose of lorazepam intravenously for sedation during a procedure. The nursing priority would be to assess for: ataxia and confusion. respiratory disturbances and partial airway obstruction. seizures. leukopenia and diplopia.
respiratory disturbances and partial airway obstruction. Explanation: A priority assessment would be for respiratory disturbances and partial airway obstruction. These adverse effects usually occur when a high dose of the drug is given prior to a procedure. Ataxia and confusion are also adverse effects of lorazepam, but are seen mostly in older adults. Leukopenia and diplopia are not adverse effects specific to intravenous administration but are general hematologic and ophthalmic adverse effects that can occur in anyone of any age with any method of lorazepam administration. Seizures can be an adverse effect of the drug with any type of administration. However, lorazepam is usually administered for seizures.
The nurse is assessing a client who has been prescribed lorazepam. Which of the client's current signs and symptoms should cause the nurse to suspect that the client is experiencing withdrawal? uncharacteristic memory lapses unstable blood sugars in recent days current mood is described as "depressed" severe insomnia for the past several nights
severe insomnia for the past several nights Explanation: Common signs and symptoms of benzodiazepine, like lorazepam, withdrawal include increased anxiety, psychomotor agitation, insomnia, irritability, headache, tremor, and palpitations. Memory lapses, unstable blood sugars, and depression are not typical.
The nurse is providing education to a client who has been prescribed eszopiclone. What information should the nurse include? the importance of taking the drug with food the importance of taking the drug immediately before going to bed the need to supplement the medication with a benzodiazepine the need to have monthly blood work drawn during treatment
the importance of taking the drug immediately before going to bed Explanation: People should take eszopiclone immediately prior to going to bed because of its rapid onset of action. It does not need to be taken with food and should not be combined with benzodiazepines. Regular blood work is not indicated.
